Breastfeeding Motivators and Barriers in Women Receiving Medications for Opioid Use Disorder

Abstract

Background:

Women with opioid use disorder (OUD) are encouraged to breastfeed, but have lower breastfeeding rates than the general population.

Objective:

We examined self-reported barriers and motivators for breastfeeding in women with OUD and the relationship between maternal/postnatal factors and breastfeeding noninitiation/discontinuation.

Materials and Methods:

A cross-sectional design was used; 40 women with OUD who were eligible to breastfeed were included. Information about breastfeeding initiation, duration, barriers/motivators, demographic characteristics, and self-efficacy was obtained through semi-structured interviews at 4–8 weeks postpartum. Wilcoxon rank sum or Fisher's exact test was used to examine the relationship between maternal/postnatal factors and never-initiated/discontinued breastfeeding.

Results:

Respondents were 29.3 ± 5.3 years old; most were prescribed buprenorphine (77.5%); and 36.8% of infants were treated for neonatal opioid withdrawal syndrome with methadone or morphine. Most (75.0%) participants initiated breastfeeding; 50.0% continued breastfeeding at 4–8 weeks. The most common motivators included infant health (100%) and bonding (45.0%). On average, women reported discontinuing breastfeeding at 3.3 ± 1.1 weeks postpartum. The most common barriers were concerns regarding transfer of medications or other substances to the infant (50.0%) and concerns about breast milk supply (35.0%). Mean self-efficacy scores were similar among those who continued versus never-initiated/discontinued breastfeeding (33.5 versus 33.0; p = 0.388). Neonatal intensive care unit admission was associated with never-initiated/discontinued breastfeeding (p = 0.047).

Conclusion:

Women with OUD share many similar motivators and barriers to breastfeeding with the general population. Unique concerns include infant exposure to medications or substances, even in those who are eligible to breastfeed, which should be addressed by targeted education for patients and providers.

Introduction

Opioid use in pregnancy increased 333% from 1999 to 2014.¹ For the past several decades, New Mexico drug and alcohol overdose rates have been among the highest in the nation, with some counties having rates four times the national average.² This alarming statistic affects all segments of the New Mexico population. In 2014, 14.8 per 1,000 infants in the state had prenatal exposure to opioids.¹ Medications to treat opioid use disorder (MOUD), such as methadone and buprenorphine, decrease the risk of overdose, criminal involvement, relapse, and the transmission of diseases associated with intravenous drug injection; they are also associated with increased prenatal care.³

Although small amounts of methadone and buprenorphine are transferred into human milk, the Academy of Breastfeeding Medicine (ABM), American Academy of Pediatrics (AAP), and the American College of Obstetricians and Gynecologists (ACOG) recommend breastfeeding for women on MOUD, unless contraindications exist, such as continued substance use or HIV infection.^4–7 In addition to the well-established medical and neurodevelopmental advantages of breastfeeding, it also decreases the severity of neonatal opioid withdrawal syndrome (NOWS) and the need for pharmacologic treatment of NOWS.^8–10 Breastfeeding may also be particularly important for women with OUD and their infants to attenuate risks of reduced parent-child bonding.^10–13

Striking disparities exist in the initiation and duration of breastfeeding in women on MOUD compared to the general population. Nationally, 83% of women initiate breastfeeding and 57% are still breastfeeding at 6 months postpartum.¹⁴ In a review of breastfeeding literature among women on MOUD, seven out of nine evaluated studies reported breastfeeding initiation rates at least 10% lower than the U.S. national average.¹⁵ Despite these health disparities, there is limited research on breastfeeding barriers and motivators among women with MOUD, whose social milieu often differs from the general population.¹⁶

The primary objectives of this cross-sectional study were to (1) identify key barriers and motivators of breastfeeding in women with MOUD; (2) examine the relationship between perceived self-efficacy and reported breastfeeding at 4–8 weeks; and (3) examine the relationship between maternal and postnatal factors and failure to initiate or early discontinuation of breastfeeding. We hypothesized that (1) infant health benefits would be the most important motivator for breastfeeding and (2) low self-efficacy, low socioeconomic status or education level, and concerns about transfer of medications and substance use would be key barriers to breastfeeding among women on MOUD.

Materials and Methods

Study design, setting, and sample

This was a cross-sectional study of postpartum women on MOUD at the University of New Mexico (UNM). The UNM Human Research Review Committee approved the study; all participants provided written informed consent. Study participants were recruited in 2017–2018 from the UNM Milagro program, which provides prenatal and postnatal care for women with substance use disorders. Approximately 200 women receive care through Milagro each year (∼85% with OUD) and about 170 deliver children while in the program. The majority give birth at UNM Hospital (UNMH)—a designated Baby-Friendly hospital. UNMH utilizes guidelines adopted from the ABM Clinical Protocol, which encourages women on MOUD without recent relapse to opioids or other illicit drugs to breastfeed.^4,17 Breastfeeding information is typically discussed with Milagro patients throughout their pregnancy, and an infant feeding plan is recorded in the electronic medical record.

After birth, infants typically room-in with their mother, while NOWS observation is performed for 96 hours, unless another medical problem requires their admission to the level II nursery or neonatal intensive care unit (NICU). All infants at risk for NOWS receive supportive non-pharmacologic treatment, while rooming-in with their mother (at the mother-baby unit or another rooming-in unit at UNMH) and, if needed, pharmacologic treatment. Infants may also be transferred to the level II nursery for NOWS treatment if the mother is unable to stay in the hospital for the full 96 hours of infant observation.

The target population for this study was women on MOUD who were attending a 4–8 week postpartum visit at the Milagro program. Inclusion criteria for participation were as follows: (1) at least 18 years of age; (2) able to give informed consent in English; (3) receiving MOUD (either methadone or buprenorphine) prenatally; and (4) met institutional eligibility criteria for breastfeeding, including abstinence from illicit drugs. Women were excluded if they were advised not to breastfeed by a Milagro provider.

Data collection

Patients were approached at a postpartum visit by a research assistant in a private room, either before or after their clinic visit, to determine eligibility and ascertain interest in participation. If eligible and interested, written informed consent was obtained. Participants completed a semi-structured interview with questions about breastfeeding initiation, current breastfeeding status, key barriers and motivators to breastfeeding, self-efficacy, demographic information, and participation in social services, such as the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Questions were adapted from the Centers for Disease Control and Prevention's (CDC) Infant Feeding Practices Study II Infant Month 2 Questionnaire.¹⁸

Participants who reported breastfeeding at the time of the interview were asked to identify all motivators for breastfeeding (multiple responses allowed), and to choose the most important factor that contributed to their continued breastfeeding. Participants who reported discontinued breastfeeding were asked the age of their infant at the time of discontinuation (in days or weeks); they were also asked to identify all of the reasons and the most important reason for discontinuing or never initiating breastfeeding. The research assistant coded participants' verbal responses by selecting from a predetermined list of options. Responses that did not fit within one of the listed categories were coded as “other” and further specified with a written description.

A validated eight-item self-efficacy questionnaire, the New General Self-Efficacy (NGSE) scale, was administered as part of the interview.¹⁹ The NGSE scale has a high reliability and assesses the degree to which participants believe they can overcome obstacles and achieve goals.¹⁹ Finally, participants were asked a series of demographic questions regarding age, marital status, race/ethnicity, education level, employment outside the home, enrollment in WIC, breastfeeding education during pregnancy, and social support for breastfeeding. The research assistant also abstracted information from the electronic medical record on medical characteristics, such as mode of delivery, hospital unit where the family stayed after birth, hepatitis C virus (HCV) status, and whether an infant had NOWS requiring pharmacological treatment. Study data were collected and managed using REDCap.²⁰

Data analysis

Data were analyzed using SAS, version 9.4 (SAS Institute, Inc., Cary, NC). Descriptive statistics (frequencies and means) were used to summarize demographic characteristics, breastfeeding barriers and motivators, and self-efficacy scores. A two-sided Wilcoxon rank sum test or Fisher's exact test was used, as appropriate, to identify relationships of never-initiated or discontinued breastfeeding with demographic variables, gestational age at birth, mode of delivery, duration of hospital stay, self-efficacy score, maternal MOUD type, infant NOWS treatment, employment, WIC enrollment, hospital unit after delivery, and social support.

Results

The study population included 40 women on MOUD (22.5% on methadone and 77.5% on buprenorphine), interviewed on average at 5.3 ± 1.3 weeks postpartum (Table 1). Most participants identified as white (90.0%) and Hispanic/Latina (77.5%), had an education level of a high school degree or lower (60.0%), and were either single or separated/divorced (52.5%). The majority (80%) were enrolled in WIC. More than one-third (36.8%) of study infants received pharmacologic treatment for NOWS. Only 7.9% of infants were discharged at the same time as their mother. More than one-third of infants were admitted to either a level II nursery (32.5%) or the NICU (35.0%) at some point during hospitalization (note: categories are not mutually exclusive).

Table 1.

Participant Characteristics (n = 40)

Characteristics	Mean ± SD
Maternal age at interview (years)	29.3 ± 5.3
Time of postpartum interview (weeks)	5.3 ± 1.3
Gestational age of infant at birth (gestational weeks)	38.5 ± 1.9
Duration of infant hospital stay (days)	12.7 ± 12.2^a
Maternal self-efficacy score, median (IQR)	33.0 (32.0; 38.0)
	n (%)
Parity: primiparous	11 (27.5)
Preterm delivery	7 (18.0)
Maternal medications for OUD
Methadone	9 (22.5)
Buprenorphine	31 (77.5)
Marital status
Single, never married	19 (47.5)
Married, living with spouse	4 (10.0)
Not married, living with partner	15 (37.5)
Separated/divorced	2 (5.0)
Ethnicity: Hispanic/Latina	31 (77.5)
Race^b
American Indian/Alaska Native	3 (7.5)
Black/African American/Multiracial	2 (5.0)
White	36 (90.0)
Education level
Less than high school	11 (27.5)
High school degree or GED	13 (32.5)
Some college, vocational training or higher	16 (40.0)
Maternal employment outside the home at time of assessment or planned to work after maternity leave
Yes, full time	14 (35.0)
Yes, part time	13 (32.5)
Unsure/undecided	2 (5.0)
No	11 (27.5)
Participation in the WIC program
Mother only	4 (10.0)
Infant only	6 (15.0)
Both mother and infant	22 (55.0)
Neither mother nor infant	8 (20.0)
Mode of delivery
Vaginal	33 (82.5)
Cesarean section	7 (17.5)
Identified a social support person who has breastfed	29 (72.5)
Infant discharged at same time as the mother	3 (7.9)
Infant unit of stay after delivery^c
Level II nursery	13 (32.5)
NICU	14 (35.0)
Mother-baby unit	29 (72.5)
Another rooming-in unit	5 (12.5)
Infant received treatment for NOWS	14 (36.8)

Neonatal outcome variables were missing in two subjects who delivered outside of UNMH system.

Median (IQR) duration of hospital stay: 5.5 (5, 20) days.

Women were allowed to choose more than one race.

Categories are not mutually exclusive due to transfer between hospital units.

GED, General Education Diploma; IQR, interquartile range; NICU, neonatal intensive care unit; NOWS, neonatal opioid withdrawal syndrome; OUD, opioid use disorder; SD, standard deviation; UNMH, University of New Mexico Hospital; WIC program, Woman, Infant, Child program.

At the time of the interview, 50.0% of participants were breastfeeding or giving expressed human milk. The remaining 25.0% never initiated breastfeeding, and another 25.0% initiated breastfeeding, but discontinued before the interview at the postpartum visit. On average, women reported discontinuing breastfeeding at 3.3 ± 1.1 weeks postpartum. Mean self-efficacy scores were similar among those who continued versus never-initiated or discontinued breastfeeding (33.5 versus 33.0; p = 0.388). Among those who reported continued breastfeeding, the most common motivators were infant health benefits (100.0%), bonding with the infant (45.0%), perceived convenience over formula feeding (30.0%), and encouragement from a health care provider (15.0%; Table 2). The most important reasons for continuation included infant health benefits (90.0%), encouragement from a health care provider (5.0%), and bonding with the infant (5.0%).

Table 2.

Facilitators to Breastfeeding (n = 20)

	n (%)
Reasons for continuing to breastfeed
It is important for my baby's health	17 (85.0)
It helps me to bond with my baby	9 (45.0)
It is easier than formula feeding	6 (30.0)
Helps with withdrawals for the infant	3 (15.0)
I was encouraged by a health care provider	3 (15.0)
I was encouraged to by a family member or friend	2 (10.0)
It is cheaper than formula feeding	2 (10.0)
Another reason not listed above: “Helps with postpartum depression”	1 (5.0)
The most important reason mother decided to continue breastfeeding
It is important for my baby's health	18 (90.0)
I was encouraged by a health care provider	1 (5.0)
It helps me to bond with my baby	1 (5.0)

Participants were allowed to choose multiple responses; thus, categories are not mutually exclusive.

n is limited to participants who continued to breastfeed/pump at the time of the interview.

Among participants who never initiated or discontinued breastfeeding before the interview, the most common barriers cited were the use of medications/substances that might be transferred to the infant through breast milk (50.0%), not having enough breast milk (35.0%), discouragement by a health care professional (15.0%), and feeling that breastfeeding was too tiring and inconvenient (15.0%; Table 3). The most important barriers for discontinuation were concerns about infant exposure to medication/substances (35.0%), not having enough breast milk (30.0%), and having HCV (10.0%). Among patients who had Cesarean section delivery, 71.4% did not initiate or discontinued breastfeeding before the interview compared to 45.5% among women with vaginal deliveries; however, differences did not reach statistical significance (p = 0.408; Table 4). Admission in the NICU was the only significant predictor associated with never-initiated/discontinued breastfeeding (p = 0.047).

Table 3.

Barriers to Breastfeeding (n = 20)

	n (%)
Reasons for discontinued breastfeeding
I am taking a medication or other substance and did not want my child to be exposed through breast milk	10 (50.0)
I thought that I did not have enough milk	7 (35.0)
A health professional said I should not breastfeed	3 (15.0)
I did not like breastfeeding, I thought it was too tiring or inconvenient, or I wanted my body back to myself	3 (15.0)
I was worried about breastfeeding because I have HCV	2 (10.0)
My baby had trouble latching on or sucking	2 (10.0)
I tried breastfeeding before, and I did not like it or it did not work out	1 (5.0)
I could not or did not want to pump or breastfeed at work or school	1 (5.0)
I did not want to breastfeed in public	1 (5.0)
My baby was sick and could not breastfeed	1 (5.0)
Another reason not listed above: “Baby was in the ICU after delivery”	1 (5.0)
The most important reason for discontinued or never-initiated breastfeeding
I am taking a medication or other substance and did not want my child to be exposed through breast milk	7 (35.0)
I thought that I did not have enough milk	6 (30.0)
I was worried about breastfeeding because I have HCV	2 (10.0)
A health professional said I should not breastfeed	1 (5.0)
I could not or did not want to pump or breastfeed at work or school	1 (5.0)
I did not want to breastfeed in public	1 (5.0)
My baby was sick and could not breastfeed	1 (5.0)
Another reason not listed above: “Hard time getting used to breastfeeding”	1 (5.0)

Sample size is limited to those who discontinued breastfeeding/pumping or never initiated breastfeeding.

HCV, hepatitis C virus; ICU, intensive care unit.

Table 4.

The Association Between Sociodemographic and Medical Factors and Breastfeeding Status at 4–8 Weeks Postpartum (n = 40)

Characteristics	Failure to initiate or early discontinuation of breastfeeding (n = 20)	Continued breastfeeding or pumped milk (n = 20)	p ^b
Characteristics	Median (IQR)	Median (IQR)	p ^b
Maternal age at interview (years)	26.5 (23.5, 33.0)	30.5 (25.5, 34.5)	0.272
Weeks postpartum at interview	4.3 (4.0, 7.0)	6.0 (4.1, 6.0)	0.496
Gestational age at birth (weeks)	39.0 (38.0, 40.0)	38.9 (37.3, 39.5)	0.521
Duration of hospital stay (days)	6.0 (5.0, 25.0)	5.0 (4.0, 11.0)	0.280
Maternal self-efficacy score	33.0 (31.5, 37.0)	33.5 (32.0, 39.0)	0.388
	n (%^d)	n (%^d)	p
Parity: primiparous	4 (36.4)	7 (63.6)	0.288
Preterm delivery	3 (42.9)	4 (57.1)	0.695^c
Type of MOUD			0.451^c
Methadone	3 (33.3)	6 (66.7)
Buprenorphine	17 (54.8)	14 (45.2)
Marital status			0.342
Single or Separated/divorced/widowed	12 (57.1)	9 (42.9)
Married/living with a partner	8 (42.1)	11 (57.9)
Ethnicity: Hispanic/Latina	16 (51.6)	15 (48.4)	1.000^c
Race: white	18 (50.0)	18 (50.0)	1.000^c
Education level			0.100
Less than high school	8 (72.7)	3 (27.3)
High school degree or GED	7 (53.8)	6 (46.2)
Some college, vocational training, or higher	5 (31.2)	11 (68.8)
Infant received treatment for NOWS	9 (64.3)	5 (35.7)	0.272
Infant discharged with mother	1 (33.3)	2 (66.7)	0.595
Maternal employment outside the home at time of assessment or planned to work after maternity leave			0.926
Yes, full time	7 (50.0)	7 (50.0)
Yes, part time	7 (53.8)	6 (46.2)
No or unsure/undecided	6 (46.2)	7 (53.8)
Participation in the WIC program			0.695^c
Yes, for mother or infant	17 (53.1)	15 (46.9)
No, for neither mother nor baby	3 (37.5)	5 (62.5)
Mode of delivery			0.408^c
Vaginal	15 (45.5)	18 (54.6)
Cesarean section	5 (71.4)	2 (28.6)
Infant unit of stay after delivery^a
Level II nursery	7 (53.8)	6 (46.2)	0.736
NICU	10 (71.4)	4 (28.6)	0.047
Mother-baby unit	13 (44.8)	16 (55.2)	0.288
Rooming-in unit	3 (60.0)	2 (40.0)	1.00^c
Identified a social support person who has breastfed	14 (48.3)	15 (51.7)	0.723

p-Value in bold indicates the only p-value which was significant (<0.05).

Neonatal outcome variables were missing in two subjects who delivered outside of UNMH system.

Categories are not mutually exclusive.

Wilcoxon rank sum test.

Fisher's exact test.

Row percentages.

GED, General Education Diploma; IQR, interquartile range; MOUD, medications for opioid use disorder; NICU, neonatal intensive care unit; NOWS, neonatal opioid withdrawal syndrome; UNMH, University of New Mexico Hospital; WIC program, Woman, Infant, Child program.

Discussion

Breastfeeding for women on MOUD without contraindications is strongly supported by the ABM, ACOG, and AAP. In our study, 75% of eligible women on MOUD initiated breastfeeding, similar to the 72% and 80% initiation rates in two other recent studies of women with MOUD,^21,22 and slightly below the estimated national rate of 83% in the general population.^23,24 With respect to the continuation rates, two of the studies included in a recent systematic review reported that only 50–66% of women on MOUD continued breastfeeding at 6–8 weeks postpartum,^25,26 and the mean duration of breastfeeding was 5.9 ± 6.5 days.^15,27 The mean duration of breastfeeding was longer in our study (3.3 ± 1.1 weeks) compared to these earlier estimates.

Similar to our findings, prior qualitative studies of women on MOUD identified infant health benefits, bonding, and financial reasons as important motivators for breastfeeding.^21,22,28,29 One of the benefits reported in earlier studies was alleviation of NOWS symptoms.^21,22 In our study, 15.0% of participants who continued to breastfeed stated that their primary reason was to ease withdrawal symptoms for their infant.

The most important reason for never initiating or early discontinuation of breastfeeding was concern about neonatal exposure to medications or substances, consistent with other studies.^21,22,28,29 Although the safety of breastfeeding while on MOUD is emphasized by physicians and staff during prenatal care, it is possible that women are receiving conflicting information on the safety of breastfeeding, while on MOUD, from family members or some medical staff.

In our study, all participants met the hospital eligibility requirements for breastfeeding, yet three subjects reported that they did not breastfeed because they were discouraged by a health care professional. It is unclear if this response was influenced by “social desirability” bias, or confounded by concerns about transfer of MOUD, alcohol, or illicit substances into breast milk. Other studies cited maternal concerns about an infant becoming “addicted” to methadone or “getting high” as barriers.^28,29 Since the greatest barrier to breastfeeding in multiple studies was a concern about the transfer of medications, future efforts are needed to educate health care providers and pregnant and postpartum women on MOUD, and the general public on the safety of breastfeeding with MOUD.

Concern about breast milk supply is consistent with research in both women on MOUD and the general population.^29,30 However, women on MOUD may require additional breastfeeding support related to infant latch and suck, milk transfer, and breast milk fortification or supplementation because of infant health issues associated with NOWS. NOWS may cause oral motor dysregulation, leading to poor feeding and poor milk transfer, which could eventually cause a lower milk supply.³¹ In addition, NOWS may cause infant weight loss, leading to the need for breast milk fortification or supplementation.³² Howard et al. found that mothers felt disappointed in themselves when supplementation was necessary.²¹ It is important to help breastfeeding women on MOUD to understand that the need for fortification or supplementation is not related to poor milk supply or breastfeeding skills, but is instead attributable to physiological complications related to NOWS.²¹ Efficient and accurate patient-provider communication from the entire medical support team is crucial in reassuring the patient that supplementation might be necessary, without inducing a sense of guilt or inadequacy in maternal skill.

The potential of HCV transmission was similarly noted as a barrier to breastfeeding in our and other studies.^21,29 At UNMH, the CDC's recommendation for breastfeeding with HCV is reviewed during prenatal care, stating that it is generally considered safe to breastfeed with HCV, but that if nipples are cracked or bleeding, it is recommended that the patient gives expressed milk only until her nipples are healed.³³ It is possible that women in our study stopped breastfeeding because they developed cracked nipples and were concerned about transmission, or that not all of the health care providers in the hospital were aware of the CDC recommendations.

NICU admission was the only significant factor associated with noninitiation or early discontinuation of breastfeeding. This may be due to infants in the NICU having an overall more complex health status and therefore increased difficulties establishing or maintaining breastfeeding. Alternatively, it could be because infants in the NICU are more likely to be separated from their mothers for at least part of the day. At UNMH, there are chairs for a mother to sit next to her infant, but there are no beds, and parents are required to leave the unit during shift changes. Rooming-in has been found to be one of the most effective interventions to promote breastfeeding³⁴; however, this is often logistically challenging for intensive care nurseries.

Other studies of women on MOUD also recognized these challenges, including difficulties with transportation to and from the hospital after discharge.²² The finding that only 7.9% of infants were discharged at the same time as their mothers in our study was not surprising, given the required 96-hour observation period for NOWS, and much longer hospitalization of infants requiring pharmacological treatment for NOWS. Most women are discharged 2 days after a vaginal birth and 4 days after a Cesarean section. Similar to our study, the majority of infants (73.0%) in the study by Hicks et al. remained hospitalized at the time of maternal discharge.²² Some women may be able to room in with their infant after discharge, but women on methadone need to travel to a methadone clinic daily for dosing after their hospital discharge.

In this study, there was no significant association between self-efficacy and breastfeeding. A relatively small sample size might have contributed to the observed lack of association. In addition, a prior research study demonstrated a strong association between breastfeeding self-efficacy and social support,³⁵ while in our study, about one-third of participants did not receive social support from a person who has breastfed. Prior research also identified negative impact of internal and external stigma on maternal self-efficacy.²¹ The role of breastfeeding and general self-efficacy, maternal mental health, social support, stigmatization and discrimination, and socioeconomic environment on breastfeeding outcomes should be examined in future studies.

Hospitals that serve women with OUD should consider including content specific to the concerns of this population in required provider trainings, breastfeeding education classes, and peer support models. Specific content that should be addressed includes the safety of breastfeeding with MOUD, special considerations of breastfeeding an infant with NOWS, and breastfeeding with HCV. Working on interventions to prevent the need for NICU admission or changing the NICU environment to support breastfeeding by allowing rooming-in may also positively impact breastfeeding for women with MOUD. Future studies should examine health care provider knowledge, attitudes, and practices, as well as educational outreach and training programs for hospital staff on substance use disorders, HCV, and MOUD, and address the potential for unconscious bias to provide more supportive environments for breastfeeding in this population.

Limitations

First, our results may not be representative of or generalizable to all women with MOUD. The majority of patients in this study were Hispanic, which we view as a strength, given the underrepresentation of this group in research. Second, given the sensitive nature of some questions, we acknowledge a potential for recall or social desirability bias. However, interviews were conducted in a non-judgmental manner by a research assistant who was not a part of the medical team. Third, questions regarding maternal concerns about the transfer of illicit substances into breast milk were worded generally as concerns about medication and other substance transfer; thus, we cannot differentiate concerns for infant exposure to MOUD and other medications versus illicit drugs. A broader question was chosen by design, however, to minimize discomfort level of the interview questions and associated reporting bias, as well as potential legal implications.

Conclusions

While some breastfeeding concerns are shared with the general population of postpartum women, such as low milk supply, women on MOUD have unique concerns regarding medication transfer. In addition, patients on MOUD might receive mixed messages from their health care team about breastfeeding. Future studies should develop and test the effectiveness of interventions to promote breastfeeding, as well as provide education and support tailored to the needs of women on MOUD. Effective breastfeeding support for women with OUD is needed to address health disparities in this field, given the multiple health benefits of breastfeeding for both mother and infant.

Footnotes

Acknowledgments

The authors would like to acknowledge Sandra Cano, MA, for assistance with coordination of research activities and Laura Garrison, MA, for editorial assistance. We are also in debt to the Milagro program staff and patients.

Disclosure Statement

No competing financial interests exist.

Funding Information

This project was supported by a grant from the University of New Mexico College of Pharmacy (PI: Bakhireva).

References

Haight

, Ko

, Tong

, et al. Opioid use disorder documented at delivery hospitalization—United States, 1999–2014. MMWR Morb Mortal Wkly Rep, 2018; 67:845–849.

New Mexico death certificate database. New Mexico Department of Health. 2019. Available at http://ibis.health.state.nm.us (accessed March 19, 2019).

Klaman

, Isaacs

, Leopold

, et al. 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. J Addict Med, 2017; 11:178–190.

Reece-Stremtan

, Marinelli

. ABM clinical protocol #21: Guidelines for breastfeeding and substance use or substance use disorder, revised 2015. Breastfeed Med, 2015; 10:135–141.

American College of Obstetricians and Gynecologists. Opioid use and opioid use disorder in pregnancy. Committee opinion no. 711. Obstet Gynecol, 2017; 130:e81–e94.

American Academy of Pediatrics Committee on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics, 2012; 129:e827–e841.

Chantry

, Eglash

, Labbok

. ABM position on breastfeeding-revised 2015. Breastfeed Med, 2015; 10:407–411.

Short

, Gannon

, Abatemarco

. The association between breastfeeding and length of hospital stay among infants diagnosed with neonatal abstinence syndrome: A population-based study of in-hospital births. Breastfeed Med, 2016; 11:343–349.

Yonke

, Maston

, Weitzen

, et al. Breastfeeding intention compared with breastfeeding postpartum among women receiving medication-assisted treatment. J Hum Lact, 2018; 35:71–79.

10.

Horta

, de Sousa

, de Mola

. Breastfeeding and neurodevelopmental outcomes. Curr Opin Clin Nutr Metab Care, 2018; 21:174–178.

11.

Ross

, Graham

, Money

, et al. Developmental consequences of fetal exposure to drugs: What we know and what we still must learn. Neuropsychopharmacology, 2015; 40:61–87.

12.

U.S. Department of Health and Human Services. Child maltreatment 2016. Available at https://www.acf.hhs.gov/sites/default/files/cb/cm2016.pdf#page=29 (accessed May 21, 2019).

13.

Kremer

, Kremer

. Breastfeeding is associated with decreased childhood maltreatment. Breastfeed Med, 2018; 13:18–22.

14.

Centers for Disease Control and Prevention. Breastfeeding facts. Available at https://www.cdc.gov/breastfeeding/data/facts.html (accessed September 23, 2018).

15.

Tsai

, Doan

. Breastfeeding among mothers on opioid maintenance treatment: A literature review. J Hum Lact, 2016; 32:521–529.

16.

Yang

, Gao

, Ip

, et al. Predictors of breast feeding self-efficacy in the immediate postpartum period: A cross-sectional study. Midwifery, 2016; 41:1–8.

17.

UNM Hospital MCH Committee. UNMH breastfeeding, substance abuse, and infectious diseases guideline. Available at http://unmfm.pbworks.com/w/file/76803359/UNM%20Breastfeeding%20%26%20Substance%20Abuse%20Policy.pdf (accessed February 28, 2018).

18.

Centers for Disease Control and Prevention. Infant feeding practices study II and its six year follow up: The questionnaires. Available at https://www.cdc.gov/breastfeeding/data/ifps/questionnaires.htm (accessed November 15, 2016).

19.

Chen

, Gully

, Eden

. Validation of a new general self-efficacy scale. Org Res Methods, 2001; 4:62–83.

20.

Harris

, Taylor

, Thielke

, et al. Research electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform, 2009; 42:377–381.

21.

Howard

, Wachman

, Levesque

, et al. The joys and frustrations of breastfeeding and rooming-in among mothers with opioid use disorder: A qualitative study. Hosp Pediatr, 2018; 8:761–768.

22.

Hicks

, Morse

, Wyant

. Barriers and facilitators of breastfeeding reported by postpartum women in methadone maintenance therapy. Breastfeed Med, 2018; 13:259–265.

23.

Centers for Disease Control and Prevention. Breastfeeding among U.S. children born 2002–2014, CDC National Immunization Survey. Available at https://www.cdc.gov/breastfeeding/data/nis_data/results.html (accessed February 27, 2018).

24.

Schiff

, Wachman

, Philipp

, et al. Examination of hospital, maternal, and infant characteristics associated with breastfeeding initiation and continuation among opioid-exposed mother-infant dyads. Breastfeed Med, 2018; 13:266–274.

25.

O'Connor

, Alto

, Musgrave

, et al. Observational study of buprenorphine treatment of opioid-dependent pregnant women in a family medicine residency: Reports on maternal and infant outcomes. J Am Board Fam Med, 2011; 24:194–201.

26.

O'Connor

, Collett

, Alto

, et al. Breastfeeding rates and the relationship between breastfeeding and neonatal abstinence syndrome in women maintained on buprenorphine during pregnancy. J Midwifery Womens Health, 2013; 58:383–388.

27.

Wachman

, Byun

, Philipp

. Breastfeeding rates among mothers of infants with neonatal abstinence syndrome. Breastfeed Med, 2010; 5:159–164.

28.

McGlothen

, Cleveland

, Gill

. “I'm Doing the Best That I Can for Her”: Infant-feeding decisions of mothers receiving medication-assisted treatment for an opioid use disorder. J Hum Lact, 2018; 34:535–542.

29.

Demirci

, Bogen

, Klionsky

. Breastfeeding and methadone therapy: The maternal experience. Subst Abus, 2015; 36:203–208.

30.

Odom

, Li

, Scanlon

, et al. Reasons for earlier than desired cessation of breastfeeding. Pediatrics, 2013; 131:e726–e732.

31.

Hart

, Viswanathan

, Jadcherla

. Persistent feeding difficulties among infants with fetal opioid exposure: Mechanisms and clinical reasoning. J Matern Fetal Neonatal Med, 2019; 32:3633–3639.

32.

Dryden

, Young

, Campbell

, et al. Postnatal weight loss in substitute methadone-exposed infants: Implications for the management of breast feeding. Arch Dis Child Fetal Neonatal Ed, 2012; 97:F214–F216.

33.

Centers for Disease Control and Prevention. Hepatitis B or C infections. Available at https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/maternal-or-infant-illnesses/hepatitis.html (accessed April 14, 2019).

34.

MacMillan

KDL

, Rendon

, Verma

, et al. Association of rooming-in with outcomes for neonatal abstinence syndrome: A systematic review and meta-analysis. JAMA Pediatr, 2018; 172:345–351.

35.

Maleki-Saghooni

, Amel Barez

, Karimi

. Investigation of the relationship between social support and breastfeeding self-efficacy in primiparous breastfeeding mothers. J Matern Fetal Neonatal Med, 2019:1–6.