Study design and population

This qualitative study explored dynamics among organizations involved in caring for pregnant and parenting women with SUDs. We recruited participants from various sectors, including criminal legal, CWS, community-based care organizations (CBOs), health agencies, SUD treatment, and other healthcare settings that have experience with care coordination for pregnant and/or parenting women using substances in New York State. Eligible participants were aged 18 or older and employed at relevant organizations. Potential interview participants were identified using publicly available governmental and non-governmental databases and websites, professional networks, and recommendations from participants who had already completed interviews. To capture the range of organizations and activities related to pregnant and parenting women, potential participants were purposively sampled based on job title, institutional affiliation, geography, and the level of involvement working with pregnant and parenting women. We also used snowball sampling, asking participants to refer potential contacts. Potential participants were contacted through email outreach using e-Flyers that indicated the eligibility criteria. Participants were eligible if they were currently employed in the criminal justice system, child welfare services, substance use treatment, or prenatal/postpartum care, and had direct experience working with pregnant or parenting women who use drugs or have a substance use disorder. This criterion ensured the inclusion of professionals with relevant, practice-based insights across key service systems.

Ethics statement

Prior to conducting interviews, trained research coordinators conducted eligibility screening and obtained verbal informed consent. At the start of each interview, the interviewer used a verbal consent script to explain the study’s purpose, risks, and benefits, address participant questions, and obtained verbal consent for participation and audio recording. We preferred verbal consent to reduce participant burden and support informed decision-making. Interviewers documented verbal consent in accordance with IRB-approved procedures. This process, including our request for a waiver of documentation of consent for obtaining verbal consent, was approved by the NYU Langone Health’s IRB (Protocol #i22-00053).

Data collection

Between April 2022 and April 2023, trained interviewers (SC, EK, CK) conducted one-on-one semi-structured interviews via Zoom. The semi-structured interview guide explored organizational priorities and culture; experiences coordinating care for pregnant and parenting women with SUDs in New York State; and factors in the external environment of the participating organizations (e.g., system-level policies or priorities for resource allocation and relative priority of coordinating care for pregnant and parenting women) (S1 Fille). Probing questions were used to encourage participants to provide detailed accounts. Interviews, which lasted approximately 45–60 min, were audio-recorded and professionally transcribed. At the end of the interviews, brief surveys collected data on socio-demographics and professional characteristics (e.g., self-reported age, sex, gender, race/ethnicity, current position, time at organization and in current position). After the interview, participants were asked if they could recommend women who met the study objectives and were willing to participate. Participants received $30 e-gift cards for their time.

Data analysis

A summary was created immediately after each interview and reviewed with the research team during biweekly regular study meetings. Participants were recruited until thematic saturation was reached. Summaries allowed for high-level analysis during ongoing data collection, facilitated codebook development using the interorganizational framework, and reduced the number of initial codes requiring re-review and re-coding of transcripts during data analysis [18]. Thematic analysis was used to analyze and code the transcripts [19] (S1-S2 File). This analysis aimed to uncover patterns of interaction, collaboration, and potential areas for improvement within and across stakeholder groups. Dedoose software was used to code transcripts [20]. Each transcript was coded by at least two independent coordinators (SC, EK, IVD, JO). Coding disagreements were resolved through discussion. A continuous and iterative process of coding, categorizing, and reviewing the raw data was used to reflect on the analysis at various points and make revisions to the codebook.

Study sample

30 participants were interviewed for this study. Participants were mostly female (90%), and the average age of participants across all groups was 45 years. Participants were affiliated with SUD treatment and other healthcare service providers (n = 10), CWS providers (n = 10), criminal legal stakeholders (n = 6), and other CBOs (n = 4), as illustrated in Table 1. SUD treatment and other healthcare service providers included participants working at both hospital and non-hospital-based service providers. CWS providers included participants affiliated with or contracted by the Office of Children and Family Services (OCFS)/Department of Social Services (DSS) or the Administration for Children’s Services (ACS). Criminal legal stakeholders included participants affiliated with different areas of the legal system, such as courts and correctional services. Non-Hispanic White participants were the most prevalent (70%), followed by non-Hispanic Black participants (13.3%), non-Hispanic Asian participants (10%), and Hispanic participants (6.7%).

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Table 1. Participant Demographics.

https://doi.org/10.1371/journal.pone.0336029.t001

Navigating complex needs and services

Participants described clients as having complex needs, including those related to pregnancy/parenting, substance use and polysubstance use, and legal involvement. In addition, clients often faced other social and health challenges, such as adverse childhood experiences, food insecurity, housing instability, trauma, mental health conditions, domestic violence, and employment issues. These overlapping needs make coordinated care and collaboration across agencies salient.

“A lot of the problems that come to me are the system level problems. For example, homeless; we have a huge increase in homelessness. The other one we’re facing is with mental health; that’s probably another big one with regards especially to juveniles currently. Other agencies may not like what we’re doing and, you know, are voicing that, and we’re trying to work through that. I have involvement in a lot of the legal cases that come through as far as protective removals, terminations of parental rights, less so with child support because they don’t, it’s a more standard type of process. That’s kind of a nutshell, I guess.” (County Leadership in CWS)

“There’s definitely I’d say – out of every batch of participants – there’s also probably at least one person who’s having housing issues or employment issues. We’ve had a fair amount of people who have intimate partner violence. A lot of, yeah, and all of it exacerbated by there being a baby to take care of.” (Clinician working in a SUD Treatment Program within a large medical system)

“They have trauma. That’s also another thing we’re measuring. We have a fairly high rate – because I’m just looking at what the ACES and the TSE-40 scales that we’re using – it’s a fairly higher rate of that. So, they want to just have the mental healthcare. They’re aware enough to know that they’re using substances because something happened in their past.” (Clinical Director working in a SUD Treatment Program within a large medical system)

Interorganizational arrangements and relationships

Many organizations relied on referral networks to facilitate access to services. Healthcare providers referred pregnant and parenting women with SUDs to specialized addiction treatment centers, social services, or mental health professionals. Courts often mandated treatment and required paperwork demonstrating attendance and adherence to treatment services. While these networks were useful in ensuring women accessed necessary services, they were often limited by lack of follow-up and inconsistent communication between organizations, leading to fragmented care. Another form of collaboration involved case management teams that coordinated care across multiple organizations. These teams were often led by a designated case manager who facilitated communication between healthcare providers, social services, and other community-based organizations.

Staff within healthcare systems often had social workers or “coordinators” who assisted with navigating not only health services, but also social and legal services. While close collaboration with CPS often proved beneficial for patients, staff members frequently needed to maintain some distance from CPS when working with clients.

“[Even though we work with CPS] I try really hard to gain [clients’] trust right away. I’ll usually tell them “Our goal here is to help you. We’re not associated with CPS in any way...I usually let them know that right up front.” (A staff in a healthcare system)

Another notable type of arrangement described by respondents was that between SUD treatment providers and maternity hospitals. In these examples, SUD clinics were formally affiliated with the hospitals at which their pregnant clients and other women with SUDs would give birth. While the affiliation is formal, the collaborative efforts themselves were not codified and were reliant on efforts initiated by the SUD side of the relationship. In this type of collaboration, SUD treatment providers proactively reached out to perinatal staff to provide education about substance use and SUDs in pregnancy and to advocate for individual clients to improve care for patients, decrease stigma, and prevent CPS involvement:

“Sometimes, I think some patients don’t necessarily want us to talk to their OB provider because of stigma and things like that. But I mean, it’s definitely something – especially, I think, as a birthing hospital, we really have been encouraging staff to talk to the patient about the value because I really think this could actually be helpful to the patient – especially if they’re in treatment, they’re doing good, and they have this plan of safe care. And we can talk to maybe a care coordinator at the hospital and say, “Yes, this is somebody who’s been in care with us,” and I think it could potentially avoid some unnecessary CPS calls, for instance.” (A leader in a SUD treatment service)

Overall, this theme centers on trust-building and stigma reduction in healthcare and social services for pregnant and parenting women with SUD. Providers emphasize the importance of clarifying their roles to patients, separating themselves from CPS to foster trust and encourage collaboration. By reassuring patients that their goal is supportive care, not punitive action, professionals help mitigate stigma.

“I always identify myself as “I am not CPS. I am a nurse and I’m here to make sure that you have your services in place. Is your baby developing according to the milestones?” So, there’s a very, very different flavor...Inevitably there is an immediate trust in the nurse. So, that’s what I do. I am a public health nurse, but I have a co-location with CPS.” (A nursing staff (contractor) at CWS)

Organizational level facilitators and barriers

At the organizational level, having resources (e.g., grant funding, infrastructure, personnel) that facilitate formal collaborative efforts can significantly improve the coordination of care for pregnant and parenting women with SUDs. Another organizational level facilitator is embedding healthcare professionals within CPS or CWS to enhance service delivery. For example, nurses working alongside CPS staff noted that their physical presence within the CPS office facilitated collaboration and increased referrals, ensuring that clients received the appropriate care (e.g., “had I not been there, [CPS workers] probably would not have been reminded that I might be able to do something for him [client]”).

Next, ensuring the alignment between individual staff members and organizational leaders is crucial for fostering effective collaboration. One leader emphasized that successful partnerships arise when service providers share a common goal—what is in the best interest of the family, not the interests of the providers or their organizations. This family-centered approach requires healthcare professionals to align their treatment and support strategies with the goals of the families they serve, overcoming the biases and traumas that service providers may bring to their work. By collaborating in ways that prioritize families’ needs, professionals can create more successful and sustainable outcomes.

“I think when people can come together and align with what is supposed to be in the best interests of each family, not in the best interests of us. As service providers...it’s not about us. In social services we, you know, and this is unfortunate...we come in ourselves with our own traumas, our own stereotypes, our own biases. And so, you know that can sometimes also be a barrier, but it does get in the way. And so, I think that whenever you can collaborate with somebody and those interests in that work and that treatment and support is aligning with what’s in the best interests of the family and letting that family guide us is really what I think is the most successful and have been the most successful situations.” (A staff in CWS)

However, several barriers complicate formal collaboration. A lack of resources and organizational structures to support these efforts can hinder progress as organizations struggle to coordinate care with limited personnel and funding. Staffing issues, including high turnover and understaffing, exacerbate this challenge; organizations cannot always maintain the necessary workforce to ensure continuous care.

The impact of external factors, such as COVID-19 and staff burnout, further overwhelms service providers, leading to decreased capacity for meaningful collaboration. These challenges also highlight knowledge gaps among specialists in SUD treatment, child welfare, and legal procedures, which can create misalignment in goals and hinder effective communication between organizations. As one clinician noted, for example, when workers are focused on completing paperwork, the broader picture of client engagement and motivation often gets overlooked, which could be better addressed with more frequent and open communication.

“My general impression is that ACS workers are usually very busy. So, yeah – the thing they want from us, the treatment provider, usually is attendance and view tox results. However, we do feel like there are really a lot more just beyond some of the factual things…like… how the client attendance because…really, that shows some level engagement, but that doesn’t tell a lot about the client engagement – or the motivation of change in treatment. So, I just hope the ACS worker can…yeah, communicate with us more often instead of just wanting some letter…from us.” (Clinical Coordinator in SUD treatment)

Despite these challenges, longstanding collaborations have proven successful. For example, grant-funded programs like the Regional Partnership Grant, which focuses on supporting new and expecting mothers with a history of substance use, have contributed to improved outcomes by fostering collaborative partnerships across disciplines. These formal efforts can help promote comprehensive, coordinated care for women affected by SUDs, although more organizational support and resources are necessary to maximize their potential.

Individual (staff) level facilitators and barriers

Collaboration often takes the form of individual initiatives where staff leverage their relationships to connect clients with needed services. For example, a clinician working in SUD treatment noted the importance of personal outreach, stating, “I mean well we don’t have an official partnership with our programs at the agency, but they will refer to us whenever there’s a pregnant woman in the program. They’ll definitely call us to screen them out.” (Clinician, SUD treatment in a Hospital Setting)

The presence of individuals who are dedicated to the work can make a substantial difference. One staff member from the criminal legal system remarked, “When we brought in this coordinator who really knew what she was doing, it made all the difference in the world because she was able to connect with these women, and she found these programs, mother and child programs.”

However, these individual efforts often face limitations in terms of resources and organizational support. A leader in the healthcare system emphasized that success often relies on personal relationships and time, stating, “Time is on your side in a place like this – networking, knowing your personnel, and you can pretty much get anything... Pretty much, I’m able to get everything I need, and what I need to get done, it’ll get done.” Despite the importance of networking and personal connections, the lack of structural support can undermine these efforts.

A staff member from child welfare noted, “Supervisors or managers are really pushing caseworkers or other institutions to really collaborate...I mean it can be daunting. Of course, it’s great that people are talking, but...we can talk all we want, but if there’s not the money and then the resources, that’s what’s holding [us] back.”

Lastly, a critical challenge identified was the difficulty in overcoming knowledge gaps between specialists in different service areas. A staff member in a community-based organization pointed out, “There’s definitely a misunderstanding between those who work in substance use disorder and those who work in...mental health, child welfare, other areas. I feel like there’s people who understand addiction treatment [but] don’t understand mental health services or child welfare services.” These gaps in understanding make collaboration challenging and can hinder the effectiveness of efforts, even when individuals are willing to work together.