"They talked to me like I was dirt under their feet:" Treatment and withdrawal experiences of incarcerated pregnant people with opioid use disorder in four U.S. states.

Background: Many pregnant individuals with opioid use disorder (OUD) spend time in jail, yet access to standard of care medications for OUD (MOUD) in jail is limited. Though qualitative studies of non-incarcerated pregnant and non-pregnant incarcerated individuals with OUD demonstrate complexities that must be considered in delivering effective care, studies with pregnant, incarcerated patients with OUD are lacking. Methods: We conducted semi-structured qualitative interviews from October 2020-November 2021 with pregnant and postpartum people with OUD who were currently or previously in jail in Florida, Maryland, Ohio, and Virginia. Interview guides incorporated understandings of the power dynamics of incarceration and gendered expectations of motherhood. We analyzed transcripts using descriptive phenomenology to identify themes around experiences of treatment or withdrawal in jail and upon release. Results: We interviewed 32 women, 23 pregnant and nine postpartum. Some received MOUD in jail and others endured withdrawal. All participants expressed concern for their babies. Five themes emerged: 1)lack of counseling or accurate information about MOUD in pregnancy; 2)absent, delayed, or coercive care in jail; 3)experiences of stigma and discrimination from staff and caregivers; 4)structural barriers to safe transitions and continuing MOUD; and 5)the destructive presence of child protective services for care continuity. These factors all influenced their ability to recover. Conclusions: Jails must provide OUD care that is attentive to pregnancy physiology, pregnancy-stigma, reentry needs, and patients' fetal-newborn concerns. Tailoring care specific to pregnancy and postpartum context can improve recovery success, reduce overdose, and promote intergenerational equity.