Graduation Year


Document Type




Degree Name

Doctor of Philosophy (Ph.D.)

Degree Granting Department

Public Health

Major Professor

Russell Kirby, Ph.D., M.S.

Committee Member

William Sappenfield, M.D., M.P.H.

Committee Member

Cheryl Vamos, Ph.D., M.P.H.

Committee Member

Judette Louis, M.D., M.P.H.


Clinical Recommendations, Obstetrics, Patient Care, Substance Use


Background: Prenatal opioid exposure is a growing problem in the United States with high and increasing rates of opioid use and opioid use disorder during pregnancy. Almost 23% of pregnant women enrolled in Medicaid programs filled an opioid prescription during pregnancy in 2007, marking a 21.1% increase since 2000. Maternal opioid use during pregnancy is associated with a variety of poor maternal, pregnancy and infant outcomes, including overdose, pregnancy-associated death, prematurity, low birth weight and Neonatal Opioid Withdrawal Syndrome. To optimize prenatal care and pregnancy-associated outcomes, the Alliance for Innovation in Maternal Health, in collaboration with The American College of Obstetricians and Gynecologists, released a bundle of practices to be performed by physicians and health care systems to compile clinical recommendations and evidence-based practices as well as to streamline clinical practices, which are publicly available to all practitioners and health systems. However, it is unknown to what extent these bundled practices have been implemented in inpatient and outpatient settings in west-central Florida, what facilitators and barriers to implementation of these bundled practices exist and to what extent hospital policies align with these recommended practices.

Purpose: The purpose of this study was to understand clinical obstetric management behaviors and evaluate how and why they may differ from clinical best-practices with regards to screening and identification of opioid use during pregnancy. This study has three aims: (1) describe clinical practice behaviors related to opioid use during pregnancy among physicians who treat pregnant women, (2) identify facilitators and barriers to clinical guideline implementation in both inpatient and outpatient settings and (3) determine the feasibility of obtaining these policies among delivery hospitals in the west-central Florida region and categorize the alignment between obtained written hospital policies with clinical bundle components.

Methods: This study utilized an equivalent concurrent mixed-methods approach. To describe clinical practice behaviors, qualitative interviews were performed with clinicians and staff who work with pregnant women, including obstetricians, nurses, mental health providers and community agency staff. To identify facilitators and barriers to clinical guideline implementation, both qualitative interviews and quantitative surveys were completed by clinicians and staff from a variety of patient care settings. Both the qualitative interviews and quantitative surveys were be guided by the Theoretical Domains Framework, an implementation science framework. To categorize alignment between written hospital policies with clinical bundle components, individuals participating in the online survey who work in a hospital setting were asked to submit hospital policies related to bundle components, which were categorized according to their fidelity to the clinical bundle components (e.g., full fidelity, partial fidelity, or no fidelity). Findings from Aim 1, Aim 2, and Aim 3 were triangulated across the topical area of screening and identification of opioid use to inform both future hypothesis generation and potential behavior change interventions to address identified implementation barriers in subsequent research.

Results: Between February and September 2020, a total of 60 individuals completed the online survey, among whom 15 participated in an interview through video-conferencing software. The majority of survey participants (66.7%) reported always or very often screening pregnant women for substance use. All interview participants described their drug screening practices. In outpatient obstetric settings, this generally occurs at pregnancy intake appointment, although some practices do not screen out of liability concerns and others may discharge women for positive drug screens or biologic tests. Many facilitators and barriers of screening were identified at the level of the patient, provider, practice, and community. The Maternal Opioid Recovery Effort initiative through the Florida Perinatal Quality Collaborative was identified as a major facilitator to support their screening efforts. Major barriers included the environmental context within the practice, such as staffing, social workers, available time, competing priorities, and customizable electronic medical records. In addition, many providers report training, positive past experiences, and collaborations with other providers and agencies as important facilitators. Only two policies were collected and abstracted by fidelity with recommended screening practices, which brought to light some issues with hospital policy collection. While certain practices, such as universal screening and the use of validated screening tools, were common, other recommended practices lacked specificity to accurately determine fidelity.

Implications: Additional training, staffing of, or collaboration with social workers in the outpatient obstetric setting, and having adequate and customizable electronic medical record systems would be beneficial in clinical settings to promote screening. Practices should consider having a more frequent screening routine in addition to the pregnancy intake appointment. Recommended screening practices should be updated to optimize specificity and clarity for institutions and practices to be able to identify their fidelity with best practices. Future research should focus on determining the most salient facilitators and barriers of screening recommendation implementation, which could then be mapped to the most effective behavior interventions for clinicians who work with pregnant women.