Review
Scoping Review of Barriers and Facilitators of Breastfeeding in Women on Opioid Maintenance Therapy

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Abstract

Objective

To synthesize the literature on the barriers and facilitators of breastfeeding among women on opioid maintenance therapy (OMT) to inform nursing interventions and improve breastfeeding outcomes.

Data Sources

We searched 11 databases using the following key terms: breastfeeding, barriers, facilitators, promotion, and opioid.

Study Selection

We included articles published in English since 2015 that addressed barriers and facilitators of breastfeeding in women on OMT. We did not limit our search to specific types of studies. Our search produced 65 records. After reviewing titles and abstracts, we assessed 21 full-text articles and excluded seven for lack of data related to our key terms. As a result, we included five qualitative studies, three reviews, three mixed-methods studies, two retrospective cohort studies, and one case report (14 articles) in our final review.

Data Extraction

We extracted data from each article and sorted them in a table for analysis and synthesis. Data included study purpose, research questions, design and methodology, and findings specifically pertaining to the identification of barriers and facilitators of breastfeeding for women on OMT.

Data Synthesis

We identified three themes related to facilitators of and barriers to breastfeeding: Information, Support, and Health Care System Factors.

Conclusion

The results of our review suggest that most barriers and facilitators of breastfeeding in women on OMT are manageable with improved health care practices. Primary and acute care health professionals should modify practices to minimize barriers to breastfeeding. Nurses should provide better breastfeeding education and preparation, sensitive care in the immediate postpartum period, and extended follow-up after hospital discharge for women on OMT.

Section snippets

Opioid Maintenance Therapy

Opioid maintenance therapy is the use of opioid agonists (methadone or buprenorphine) to treat OUD and was recommended for pregnant women with OUD (American College of Obstetricians and Gynecologists, 2017). The purpose of OMT is to treat withdrawal symptoms and cravings in people with opioid dependence. Pregnant women with OUD who received OMT had more consistent prenatal care, better nutrition, less risky behaviors, and better pregnancy outcomes than those who did not receive treatment (

Maternal Benefits

In their policy statement on breastfeeding, the American Academy of Pediatrics (2012) summarized the benefits of breastfeeding for all women, including reduced risk for breast cancer, ovarian cancer, Type 2 diabetes, cardiovascular disease, postpartum depression, and rheumatoid arthritis. Some evidence suggests that breastfeeding among healthy women is associated with improved mental health outcomes, including reduced anxiety (Godfrey & Lawrence, 2010; Mikšić et al., 2020). Because women with

Rates of Breastfeeding for Women on OMT

Estimates of how many women on OMT initiate and maintain breastfeeding vary considerably. In their review of nine studies with samples of 22 to 437 women, Tsai and Doan (2016) found that 8% to 81% of women on OMT initiated breastfeeding. In their chart review of 276 infants of mothers on OMT, Wachman et al. (2010) reported that 24% of the women who met institution-specific breastfeeding eligibility criteria initiated breastfeeding; of those, 60% stopped breastfeeding within 1 week. The findings

Barriers to Breastfeeding

Women with OUD are more likely than other women to have lower levels of education, lower incomes, less stable living arrangements, and fewer physical and social resources (Cleveland & Grossman, 2019). These factors likely add to their struggle to successfully adapt to developmental changes of the perinatal period, cope with newborns with NOWS, and meet the demands of their own addiction treatment.

Unlike other primates, humans are dependent on social learning to successfully initiate and sustain

Facilitators of Breastfeeding

Fewer researchers have investigated interventions to facilitate breastfeeding compared with those who have focused on barriers. Doerzbacher and Chang (2019) found a lack of evidence-based interventions currently in use to increase breastfeeding among women with OUD in their systematic review of four studies. The significant interventions all focused on alternative models of care, including integrated addiction and prenatal care, rooming in during the postpartum hospitalization, and outpatient

Methods

To facilitate a broader understanding of the needs of women on OMT who intend to breastfeed, we chose a scoping review to explore related literature. We used the principles described by Peterson et al. (2017) and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Extension for Scoping Reviews Checklist (Tricco et al., 2018) to guide our methods. These methods include clearly defining a research question in the context of current knowledge, establishing inclusion and

Characteristics of Studies

After screening titles for relevance and duplicates, we chose 14 articles for inclusion in the review, including five qualitative studies, three reviews (one systematic, one literature review, one review of evidence), three mixed-methods studies, two retrospective cohort studies, and one case report. Ten of the 14 articles are new sources of information specific to barriers and facilitators of breastfeeding for women on OMT that were not included in previous reviews.

Five of the included studies

Information

In their report on the role of law and policy to implement the Healthy People 2020 goals, Barraza et al. (2020) identified better maternity care and provider training as essential to attaining breastfeeding goals in the United States. We found that better maternity care through improved education for health care professionals is critical for breastfeeding success among women on OMT. We found that barriers and facilitators to breastfeeding among women on OMT are related to the absence or

Conclusion

Our results show that a lack of information among women, their families, and members of the health care team is the most significant barrier to successful breastfeeding in this population. Nonsupportive health care system factors that do not meet the unique needs of women on OMT and their newborns are also important barriers. Alternatively, providing accurate information and adequate support from family and friends, dedicated lactation specialists, and sensitive attitudes on the part of

Conflict of Interest

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

Funding

None.

Margaret Doerzbacher, RN, MSN, NNP-BC, is a clinical instructor, School of Nursing, Division of Family, Community, and Health Systems Sciences, University at Buffalo, State University of New York, Buffalo, NY.

References (53)

  • L. Barraza et al.

    The role of law and policy in assisting families to reach Healthy People’s maternal, infant, and child health breastfeeding goals in the United States

  • A. Channell Doig et al.

    Breastfeeding among mothers who have experienced childhood maltreatment: A review

    Journal of Human Lactation

    (2020)
  • R.R.S. Clark

    Breastfeeding in women on opioid maintenance therapy: A review of policy and practice

    Journal of Midwifery & Women’s Health

    (2019)
  • L.M. Cleveland et al.

    The mothering experiences of women with substance use disorders

    Advances in Nursing Science

    (2016)
  • L.M. Cleveland et al.

    Breastfeeding recommendations for women impacted by opioid use disorder and infants with neonatal abstinence syndrome [Webinar]

  • J.R. Demirci et al.

    Breastfeeding and methadone therapy: The maternal experience

    Substance Abuse

    (2015)
  • M. Doerzbacher et al.

    Supporting breastfeeding for women on opioid maintenance therapy: A systematic review

    Journal of Perinatology

    (2019)
  • A.M. Dozier et al.

    The relationship between life stress and breastfeeding outcomes among low-income mothers

    Advances in Preventative Medicine

    (2012)
  • J.R. Godfrey et al.

    Toward optimal health: The maternal benefits of breastfeeding

    Journal of Women’s Health

    (2010)
  • L.E. Graves et al.

    Breastfeeding and opiate substitution therapy: Starting to understand infant feeding choices

    Substance Abuse: Research and Treatment

    (2016)
  • M.L. Henninger et al.

    Predictors of breastfeeding initiation and maintenance in an integrated healthcare setting

    Journal of Human Lactation

    (2017)
  • J. Hicks et al.

    Barriers and facilitators of breastfeeding reported by postpartum women in methadone maintenance therapy

    Breastfeeding Medicine

    (2018)
  • A.P. Holmes et al.

    Breastfeeding considerations for mothers of infants with neonatal abstinence syndrome

    Pharmacotherapy

    (2017)
  • M.B. Howard et al.

    The joys and frustrations of breastfeeding and rooming-in among mothers with opioid use disorder: A qualitative study

    Hospital Pediatrics

    (2018)
  • L.M. Jansson et al.

    Neonatal abstinence syndrome

    Current Opinion in Pediatrics

    (2012)
  • L.M. Jansson et al.

    Methadone maintenance and lactation: A review of the literature and current management guidelines

    Journal of Human Lactation

    (2004)

    • Margaret Doerzbacher, RN, MSN, NNP-BC, is a clinical instructor, School of Nursing, Division of Family, Community, and Health Systems Sciences, University at Buffalo, State University of New York, Buffalo, NY.

    Mickey Sperlich, PhD, MSW, CPM, is an assistant professor, School of Social Work, University at Buffalo, State University of New York, Buffalo, NY.

    Amy Hequembourg, PhD, is the Assistant Dean for Diversity and Inclusion and an associate professor, School of Nursing, Division of Family, Community and Health Systems Sciences, University at Buffalo, State University of New York, Buffalo, NY.

    Yu-Ping Chang, PhD, RN, FGSA, FAAN, FIAAN, is the Patricia H. and Richard E. Garman Endowed Professor and Senior Associate Dean, School of Nursing, University at Buffalo, State University of New York, Buffalo, NY.

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