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Conceptualizing Neonatal Abstinence Syndrome as a Cascade of Care

A Qualitative Study With Healthcare Providers in Ohio

Syvertsen, Jennifer L., PhD, MPH; Toneff, Hannah, MA; Madden, Danielle R., PhD; Clapp, John D., PhD

Section Editor(s): Dowling, Donna PhD, RN; ; Thibeau, Shelley PhD, RNC-NIC;

doi: 10.1097/ANC.0000000000000552
Original Research

Background: The opioid epidemic remains a serious issue in the United States and presents additional challenges for women of childbearing age. An increasingly common complication of opioid use is neonatal abstinence syndrome (NAS), or infant withdrawal from in utero exposure to opioids.

Purpose: The objective of our qualitative study was to identify service needs and barriers to care in the NAS epidemic in Ohio, which has among the highest rates of opioid use and NAS in the nation.

Methods: Drawing on interviews with 18 healthcare providers, we investigated the challenges, opportunities, and service gaps in treating NAS. Open-ended questions covered opioid misuse and drug treatment, provision of and barriers to healthcare, and suggestions to improve prevention and programming. Content analysis identified major themes.

Findings: Providers were primarily women (67%) and included individuals working in healthcare administrative positions, hospital settings, clinics, and social support positions for pregnant women or new mothers. Our results suggest that rather than an acute diagnosis, NAS is better conceptualized as a “cascade of care” including (1) prevention, (2) prenatal care, including drug treatment, (3) labor and delivery, and (4) aftercare. Providers identified challenges and opportunities at each stage of the cascade that could influence NAS outcomes.

Implications for Practice: Our results suggest that greater resources, coordination, and cross-disciplinary education are urgently needed across the cascade of care to effectively address NAS.

Implications for Research: Framing NAS as a cascade of care allows researchers to identify points along a cascade where mothers and infants require enhanced care and access to social and health services.

Department of Anthropology, University of California, Riverside (Dr Syvertsen); Department of Anthropology, Case Western Reserve University, Cleveland, Ohio (Ms Toneff); University of Southern California, Los Angeles (Dr Madden); and USC Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles (Dr Clapp and Dr Madden).

Correspondence: Danielle R. Madden, PhD, Suzanne Dworak-Peck School of Social Work, University of Southern California, 3551 Trousdale Pkwy, Los Angeles, CA 90089 (

This study was conducted in affiliation with College of Social Work, The Ohio State University, Columbus.

This work was supported by the State of Ohio Department of Mental Health and Addiction Services (grant number: 15.1300) by a grant to Drs Clapp and Syvertsen at The Ohio State University.

The authors declare no conflicts of interest.

© 2018 by The National Association of Neonatal Nurses