Welcome to What to Do, Pregnant People, and Substance Use. My name is Chiara Mattresino with Kauffman & Associates, and I will manage the logistical support for this Zoom session. At the bottom of your screen, you will find a series of icons. If you have questions throughout today's session, please use the chat function, and we will address your questions either by chat or during the Q&A section at the end of the presentation. If you would like to speak aloud to ask your questions during the Q&A, please use the raise hand function under Reactions. Finally, please be aware that today's session is being recorded. Closed captioning is available by clicking the CC function. If you need technical assistance during the session, please type the issue into the chat box and one of our techs will address it as soon as possible. Without further ado, I would like to introduce today's webinar facilitator and tribal moderator for their introductions and warm welcome, Dr. Iris Prettypaint. Welcome everyone. I'd like to say that today I'm coming to you from Missoula, Montana, here on the lands of the Confederated Salish and Kootenai Tribes, and I'm going to serve as your moderator today, and I'll be going through, you know, the details of what's going to take place today. And so, with that, I'm going to turn it over to Francesca. Thank you, Dr. Prettypaint. Next slide, please. I'm Francesca Villarreal. Hi, everyone. I'm Osage and Guapaw on my father's side and Trinidadian on my mother's. I'm a TOR-TTS and a PhD student focused on examining how internalized oppression and historical trauma impact Native identity and political behavior. Today I'm going to share a few slides here about the Opioid Response Network or the ORN and the work that we are doing with TOR grantees and other Native communities. Next slide, please. We first want to acknowledge that today's webinar is funded by SAMHSA. We do have ORN and SAMHSA staff on the call today, as well as leadership and project officers that you all are being here with us today. Thank you for being here with us today and supporting this webinar series. I want to pass it to Monica Super, who's amazing and will be providing our cultural opening. Go ahead, Monica. Thank you so much, Francesca. Always good to hear your voice. So good morning, everybody. Chimusunwi. I'm Monica Super. I'm a member of the Pit River Tribe and also a Modoc descendant. I work for Kauffman and Associates, and I'm really honored to be asked to speak today and provide a cultural opening about our Indigenous mothers. As we draw closer to Mother's Day coming up, I've been in my head a lot about what my own mom means to me, the way that she has held that head of household role. She's a matriarch. She's a very protective auntie, and a term that she recently was coined by her great-nieces is grantee. She also, in her lifetime, has been burdened. She has remained hopeful. She's strong. There are days when I've seen her incredibly tired, but she, throughout all of her life experiences and challenges, she's always been deserving, and she's always been greatly needed. I have another role outside of my career, that I'm also the Himawai Cultural Rep for the Pit River Tribe, and so I'm really responsible for helping to keep our narrative and our culture alive for our Himawai people. I've been thinking a lot about our historical experiences. Some of our people in the mid-1800s were force-marched to Round Valley area and beyond. I came across recently an article that detailed the arrival of our Pit River people in San Francisco, and they had them there where the boats were docking. They were kind of like this tourist attraction, but one of the reporters wrote about our moms, our Indigenous mothers, and that although they were around the age of 20, their physical appearance resembled somebody that would be in their 70s or 80s, and that their babies were very bright-eyed and beautiful and vibrant, and it makes me think a lot about the giving of a mother, the sacrifices that our Indigenous mothers have made. Thinking about, even looking at our own language, our Pit River language, our word for mother is tatwa'i, and when you think and you take apart this word, it's derived from other Pit River words that mean crawling out, or catch up to, or sunflower, or to be, or to make, to be like something. I think that's just such a beautiful representation of how we have viewed our mothers and their roles in our lives, and so today I really lift up our moms and the long line of matriarchs that we hail from and the experiences that they've had. I personally am only able to wake up this morning and greet the sun because of the mother I come from and the long line of women that have come before her in my family, and so I want to share a song today that's specifically related to the matriarchs in my family. I made this song in our Pit River language to acknowledge the connection between our first mother, which is our land, and the infinite line of grandmothers that I come from, and when I sing this song, the intention that I put into the universe is really to spring forth that wisdom that's sitting in my genetics, like, you know, I'm calling for the assistance of the power that turns this universe to help bring all of that wisdom and knowledge forward so I can apply that to the future of my people. And so the words to this song, they mean, like, in my grandmother's time, the places and spaces that my grandmothers come from. Thank you. E tu paa ee yaa tii kaatii waai tii waai kaabiiin twee wee yaa hei hei hei yaa hei hei yaa hei hei hei yaa E tu paa ee yaa tii kaatii waai tii waai kaabiiin twee wee yaa hei hei hei yaa hei hei yaa hei hei yaa hei hei yaa E tu paa ee yaa tii kaatii waai tii waai kaabiiin twee wee yaa hei hei hei hei yaa hei hei hei yaa hei hei hei yaa Of course, so the Opioid Response Network is funded by SAMHSA to provide no-cost training and consultation to communities across the country. The ORN can assist with requests related to opioid and stimulant use, prevention, treatment, recovery, and harm reduction. Next slide, please. ORN foundational premises are to assume Native brilliance, which means to assume that each Native individual, community, program, and organization is brilliant in their own way and in their own right. To assume Native community strengths and expertise, to support sovereignty, and to follow local community leads. Our overall goal at ORN is to help fill gaps as defined by our requesters and our communities. Next slide, please. The ORN has created the Indigenous Community Response Team, or ICRT, to help support TOR grantees and other Native communities. This team is comprised of individuals who have great expertise and experience working with tribal communities across the country. Next slide, please. This map shows the different TOR regions across the country. Two Indigenous Community Response Team members are available to support each TOR region that you can see on the map. I work in the Tribal Southwest region with my counterpart Twyla Malari. Next slide, please. You can visit opioresponsenetwork.org to learn more about the ORN or to submit a TA request. Next slide, please. This is a link to a survey that we would like to share with you. We also will add it to the chat. We would be very appreciative if you could take a minute to complete the survey before you leave the session today. Well, that's it for me. Now I'll turn it right back over to Dr. PrettyPaint. Thank you. Thank you, Francesca. Well, what an honor for me today to introduce Dr. Momberg. Let me just say that she completed her doctorate in nursing practice at Arizona State University in the Edson College of Nursing. Heather is an enrolled member of the Blackfeet Nation in Montana. She has well over a decade of work experience in healthcare. She started out her career as a labor and delivery nurse, which led her to the MAT services. Her presentation today is going to be filled with her best practices and what she knows in her career. And let me just add to that that she also is involved in the revitalization of our language and ensuring that there are culturally centered resources for this topic that she'll share with us. So welcome, Heather. Hello, everybody. So you can go ahead and go to the next slide. So thank you, Iris, Dr. Iris, for the introduction. Again, my name is Heather Momberg. I like to really use my nurse Heather slide. This photo, it was sent to me by one of my friends on Snapchat, I think. She was in a presentation somewhere and she said, look, you're in this presentation at a MAT. And I don't know what it was or anything, but I love this photo because it brings me back to my beginning as a little nurse in Browning, Montana. And when I tell people my role now, I say I'm a clinical specialist at UCLA. And sometimes when I say that, it makes me feel like it takes away. Well, it doesn't take away, but it's just like doesn't encompass my experience and the time that I spent in my community and, you know, in the work that I've accomplished over the years. So I like to show this picture just for myself to kind of bring me back to like where I started and just reflect on the vision that I continue to work at. Next slide. So today we're just going to go over some learning objectives. So we're going to, you know, one goal of maternal health. We're going to talk about perinatal care. We're going to talk about causes of pregnancy related deaths in the American Indian and Alaska Native population. We're going to talk about tools and what risk assessment tools are. And then we're going to talk about culturally adapted resources and the work that has been done and the growth that we've had in our communities. Next slide. So maternal health goals. So a maternal health goal, one of the biggest goals in maternal health is to prevent maternal and neonatal death and disease. So that brings us to our next slide, which I believe is a poll. Here's a poll for you all. So what are the four phases of perinatal care? I'll just give you a little bit to think about the four phases of perinatal care. I don't know how long you keep the poll open. Good. So the four phases of perinatal care is E, all of the above. We can go ahead and go to the next slide. So we're going to talk about that today because some people think that perinatal care is when a woman becomes pregnant. But it's so much more than just when you become pregnant because what is perinatal care? It's this overarching term that encompasses how we care for women and newborn babies. And that process begins way before the time a woman actually becomes pregnant and the birth of the child as well. Several organizations are involved in developing guidelines and how we look at perinatal care in health care systems. So one of those organizations is called ACOG. And it's American College of Obstetricians and Gynecologists. And they laid out what a health care system is. And they say a health care system is responsive to the needs of families and especially women, which requires strategies to ensure access to services, identify early risks, provide linkage to appropriate levels of care, assess adherence, continuity, and comprehensive care, and to promote efficient use of resources. And so I like to really keep those in mind of that's what, when we provide perinatal care, that we're really aiming for. And so each of these things, like preconception, is prior to becoming pregnant. Prenatal and pregnancy is obviously when a person becomes pregnant. And then there's a little area around childbirth. And then we also take care of women after childbirth. Next slide. So let's talk about risk and access. Because risk and access can be connected to the lapses in the health care system accessible to the patient. So the CDC released a morbidity and mortality report in pregnancy-related deaths. And this graph shows the demographics. It shows that Black and American Indian and Alaska Native have the highest rates of pregnancy-related deaths. That'll bring us to our next poll. What do you think is the most common cause of pregnancy-related deaths among American Indian Alaska Native people? So, the correct answer is mental health conditions. So, we can go ahead and go to the next slide. So, mental health conditions consist of suicide, overdose, or poisoning related to substance use disorder, or deaths determined by maternal risk. So, and we'll explain a little bit more in the next slide. Next slide. Next slide, please. So, the CDC released data in an effort to erase maternal mortality and highlighted pregnancy related deaths among American Indian and Alaska Native persons. So, this chart shows mental health conditions as the highest underlying cause of pregnancy related death. And I had to dig a little bit further just to figure out what mental health conditions consisted of, and that's when I found out that it was suicide, that it was overdose, and other deaths that were related to mental health and substance use disorder. Next slide. So, I'm not going to read these slides, but I wanted to share them with you just to show the landscape of the opioid use disorder in American Indian and Alaska Native childcare as mentioned by this slide. And this is data that's on the IHS website. So, this is just information for you all that, you know, of course, we know that we're at the highest risk of dying from prescription overdose. And, you know, Native people with opioid use disorder encounter specific barriers to accessing services for treatment. Next slide. This slide is not necessarily specific to American Indian women, but it mentions the trends in opioid use disorder mortality in pregnancy. And just really keeping in mind that heroin use is increasing twice as fast among women than men, and nearly 50% of pregnant and substance use disorder treatment admissions are for opioids. Next slide. So, we really want to keep in mind that, you know, all, a lot of the deaths, 93% of the deaths in this report were determined to be preventable. And so, we really want to keep in mind that prevention, prevention is really goals and supporting our communities with a sound health, healthcare system rooted in prevention will improve these rates. Next slide. So, we're going to talk about access to prenatal care. Next slide. And this is just to keep in mind what we're talking about when we say what perinatal care is. Go ahead and go to the next slide. So, maternal child health in American Indian communities looks different in different regions. So, I come from where, a location where I had, we had access to an IHS hospital. I know when I relocated to California, the tribal community that I worked at had only access to a primary care setting, which then referred pregnant women to a non-tribal healthcare setting where they received their prenatal care. And, you know, just, there's a lot of stigma around IHS. And many of our communities have, you hear tons of stories about, you know, all of the stories that you hear in our communities about Indian Health Service. But, you know, I just want to say, like, I was born and raised in an IHS system. My mom worked at IHS for 40 years and raised me. You know, I grew up waiting in the waiting rooms. And if you live in an American Indian, if you live in a community, access to an IHS funded facility, your mission should really be on improving this system. And, you know, there's a lot of things that you hear. But, you know, it is a system that's accessible to us. And it is, really should be our primary goal is to improve that system that we do have access to. Next slide. So, how do we improve? How do we identify these patients? So, this was just kind of a graph that we worked on at one of the clinics that I had worked at, a tribal clinic that I worked at in California. And it was just to kind of create a roadmap for patients and identifying patients. So, this could be any patient, even, you know, pregnant or not. What do we do? How do we identify them? There's different ways that people access care. But one of the big things is making sure you're identifying the patient that you can reach out, do a phone screening if you can, get them involved with your coordinator or, you know, your substance use department if they're pregnant, if they need care. Trying to make sure that, you know, you're really creating a goal of when that first contact is. Because we do know that a lot of our, you know, some places are fortunate to have an urban setting where care is a little bit more accessible. But the reality is, you know, a lot of our tribal communities are rural. And making sure that we get them in the clinic is priority and getting them the care that they need in the evaluation. So, this was just a roadmap that we created at the time to help guide us in identifying and moving a patient along to access. Next slide. So, how do we assess risk? We want to use validated tools. And when do we screen? So, we want to screen somebody when we first come in contact with them, if we can, especially if they're pregnant. So, first prenatal visit. But we do know that sometimes, you know, pregnant women are hard to get in on their first prenatal visit. So, there's other settings that we may come in contact with pregnant women, such as OB triage, emergency room, primary care, and a CD setting. Next slide. We want to talk about what a screening tool is. So, I always want to start by saying a urine drug screen is not a screening tool. I know this has actually changed over time where it's less stigmatized. But I know, you know, anytime you want to bring up a urine drug screen, it always makes people feel a little bit anxious about that. So, we really want to keep in mind that, you know, there are screening tools available. And I'm going to talk about, we're going to talk about 5Ps in an SBIRT really quickly in the next several slides. But there are several screens that you can utilize and fit within your system. Next slide. So, the 5Ps was adapted by Massachusetts and used in healthcare and recovery. And the 5Ps is a good tool because it starts to evaluate further away from the patient. So, starting with their environment, their parents and peers, moving a little bit closer, you know, their partner, and then closer to them and really focusing on their past and their pregnancy. Next slide. And they're all, all of those, all of those questions are yes and no questions. So, based on the yes and no questions that you do receive, you're able to have, you know, answer some follow-up questions. And these are just some follow-up questions that will help you obtain more information and really begin to think about referral options. Next slide. So, we're going to talk about Taylor utilizing the 5Ps. And this is just a little short case presentation. So, Taylor is a 25-year-old gravid 2, para 1, who presents to the clinic after being discharged from OB triage two days ago. She presented to the emergency department for abdominal cramping and was surprised to find out she was pregnant. Taylor's last pregnancy was two years ago, which resulted in a 38-week uncomplicated vaginal delivery. Child protective services were involved in her care due to a positive drug screen during her last pregnancy. She has a history of methamphetamine use disorder, depression and anxiety, but otherwise no chronic health conditions, no history of surgery. She has not been in to see medical providers since her last pregnancy. She denies any history of overdose or SUD treatment. Upon review of the OB triage records, the fetal heart rate was 145. Contractions were not palpable by the nurse, but the TOCO showed uterine irritability, which resolved with fluids. The urine drug screen, there was a urine drug screen done. It did show positive methamphetamine, amphetamine, oxy. No further medication was offered at the time of Taylor's discharge. Her last menstrual period was about three or four months ago, and she cries that she didn't know she was pregnant. Next slide, which I think brings us into a poll. So, based on Taylor's story, what are some of the five Ps, I think you might have to bring up the five Ps slide, what are some of the five Ps that we recognize as a positive answer? I know this is kind of a funky slide it could have because you kind of have to see Taylor's story, but you also have to know what the five P's are. So, you could probably bring up the Taylor story as well to answer this but what are one of the five P's involved in Taylor's story. Good. So, so we do know, we do know a little bit about, you know, we do know a little bit about her past. We do know a little bit about her current pregnancy. And that's just based off of, off of what we know. And that's really important when you're kind of assessing somebody for risk. So next slide. So the five P's tool has a prompt for you, and it helps you have conversation because we begin to like open up this can of worms right when we're, when we're assessing somebody for risk we're also, you know, we're wanting to know information and and sometimes people don't feel comfortable having those conversations. They're like, I don't know, you know, and, and so I just wanted to share this with you all to kind of help to help you think about prompts or like things to say or how, how can I. How can I smoothly have this conversation and so this this these next few slides will just kind of help you really think about suggested verbal responses and actions, based on positive answers. Next slide. So we really want to, when we're caring for for pregnant women, or, you know, somebody at risk is we really want to know our community resources like what's available to Taylor, making sure you have cards or pamphlets available, who's your, you know, who are the resources that you can connect them to, you know, and really speaking up about the resources around you and providing education about all of them, and trying to understand the cultural and family norms in the community. Next slide. And this is, you know, just again to continue that to continue to keep in mind as you're providing resources as an end as you're providing those initial responses to really build rapport and feel comfortable and confident in bringing up this conversation and summarizing those thoughts and things that they say and, you know, this resource just just allows you to really think about how you're going to how you're going to have this conversation when it when it happens. Next slide. Yeah, and so that again you know these are just more, more tools to help you have that conversation. Next slide. I think there's one more slide about the five Ps and the, and the fourth, and sorry the brief interview. One of the, one of the really good things is it helps you close this conversation, you know, as you kind of think through each of these responses and and prompts you're able to really consider consider the person's response and this would be a good tool for people who are new to really practice you know if you have time within your facilities to take the newer nurses or even some of the nurses that just need practice and having these conversations maybe they're not comfortable to really utilize this tool to help you have those conversations and, you know, in native communities. We were really good at speaking with our faces so that nonverbal communication as well is important. My daughter always teases me and says why do you always have a browning face. And, but it's just our face you know our, I must have you know like a mean, a mean stare sometimes and I'm not meaning to you know and so really just kind of taking time to to practice using these tools is really important. But also you know it allows us utilizing these tools allows us to summarize the conversation and really thanking them for opening up to us. Next slide. We, you know, as we have this conversation we really want to think about making sure that we document and that we really have clear clinical considerations. When we think about Taylor's case she was having uterine irritability. So some questions that come to mind are you know when was her last uses your, your uterine irritability could mean so many things in a pregnancy world. So we really want to make sure that we address those things. So when we talk about treatment plans we want to make sure that we provide them resources to to those treatment services that are available. And really determining you know medications that issue to issue an MAT, does she take her medications, how much and how often, and any other other information that's vital to to her process. So, next slide. This is this next segment, just to talk about the pregnant family, and some barriers that we face in tribal communities and I'm gonna talk a little bit about my story and share you know just some, some growth, and in time that we've had. Next slide. As we talk about the pregnant family. I, when I was putting together resources I found in the echo toolkit they have this amazing resources. And, you know, we'll share that information but there's a resource that was developed and it's called the family care plans toolkit and I remember looking through it and I found this photo. And I love this photo because it can be interpreted in so many ways. You know you see this photo and you see a pregnant woman standing there and you see a mom or auntie or a friend or some figure that looks supporting and looks. You know, like they're, they're supporting the pregnant mom, you know, holding another child I mean that could be a friend holding their child. But I also looked at it as at this photo too and just thinking about the many pregnant women that come in that feel alone. They feel alone in their family. Even though they have a lot of supportive families. If they're using, and they're, you feel alone because you're battling this like secret battle that maybe not everybody knows about. And so when I saw this, there's just so many things that that came to mind and seeing the remembering the number of women who would come in with these big families with their big families didn't know the personal battles that they were going through. And so it just you know this this photo just meant a lot to me and I like to share it in my presentation when I talk so we can go to the next slide. We, you know, when we talk about about our communities and we talk about and this can be in any in any community but we know historical trauma has an effect on on everybody has an effect on on our health and well being and the roles, especially the roles in our families. Family roles were greatly interrupted and one of the examples that I use was just my own experience in becoming a mother. I remember I was like a 21 year old mom and even when I had my second child and my grandma would tell me, now you better make sure that you bottle feed. And I was looking at her like, you know, we hold our elders so dear to us and everything they say and I remember thinking, why is she telling me to bottle feed like that's weird, but it was because in her mind, she was thinking, these young women are these young girls, you know, and the people in my family maybe a lot of grandmas are taking care of babies, a lot of mom, you know, a lot of grandparents are unfortunately taking care of their, of their children I remember when my grandma told me that my initial thought was why but then it made sense because I was thinking about, you know, from their perspective. They're thinking, what if I need to take care of this baby I can't have it breastfed, because then I won't be able to take care of it, you know, so she's really thinking from a perspective of like I might need to step in which, which shows the interrupted roles that we experience in our families and our cultures. And I'm going to go into the next slide and it's going to go immediately into a video that I want to share, and then I'll talk about that video after, after it gets done playing. Good. This program contains subject matter and language that may be disturbing to some viewers, viewer discretion is advised. My name is john I'm 23 years old, and I live on the Blackfeet reservation in Browning, Montana, what completes me is my kids. I love my kids so much but I don't get to see them or spend time with them all the time because my daughter Jocelyn lives with my mother and thunder lives with my aunt and my uncle, and I currently live with my boyfriend Brandon, his mother's house. She can't live with her kids because my daughter Janelle is addicted to suboxone. Janelle isn't working, so she gets money any way that she can, she asks her aunts and uncles and cousins and relatives for money, she steals from people, she's stolen from her own children, she sells her food stamps, so she, I don't know how they eat. You can actually see the outline of her skull, her chest, everything you can see every bone in her body. Now if she don't get help she's, she's gonna die, let's put it that way, I'll be, I'll be truthful she's gonna die. When Janelle and I were younger we were really close. So I share this video, because it says so much about a community in just this, this one minute video and there's, and I watched it when, when this was released this video and this intervention episode was released back in, in 2016. And I remember watching it at the time and being in the background of, of this healthcare setting that you know was taking care of people in this situation, and I just remember feeling like, because we were fighting so much at the time. And, you know, when you, when you watch this video, anytime I watch it as a healthcare provider, and not necessarily specifically to this person or to the person who used but as a healthcare provider and as an advocate for services it makes me cringe, every single time I see it I'm just like, oh, because there's so much fuel. You know, so much stigma fueled in this. And it's unintentional. You know, when I look at this even this little segment so this little segment. It says a woman, you know is using two drugs readily available to her on the reservation. And then, you know, in the caption of this video when you go and look for it says don't now turns to suboxone and meth. And then you even hear the mom in this video, you hear the mom say my daughter's addicted to suboxone. And you know that there's just so much there and you can you can see the stigma around in this, you know, in this community at this time around services for MIT. But you know you also I also appreciate this video because it shows the desperation and the love and the care that this family has for this person to have to, you know, not like running to every door and trying to find answers to help their loved one, and not getting the answers that they needed. And they felt so desperate that they needed to reach out to intervention, you know, and and that just shows you know the landscape of the community at the time. So I'm going to talk a little bit about that community because I actually worked in that community. At the time, when, when, you know when this happened so you can go ahead and go to the next slide. So, so, back when I started I was a nurse at IHS prior to 2012 but I remember it was around this time frame when, when our facility. When our facility. You know, there's all these things that come down the pike from from the top level of the healthcare system now this becoming baby friendly was introduced by the World Health Organization, and they wanted to encourage breastfeeding. And so, us in our little like nursing and in our little healthcare system we were like, oh, that's gonna be fun. That's really exciting. Let's, let's go ahead and become a baby friendly and it just meant that like we're encouraging breastfeeding that our facility. And so, us being super naive we were like okay we're going to do it and it was this whole accreditation system where you had to, you know, take on these guidelines and we needed at least 10 breastfeeding charts that showed that we aligned, our care with these guidelines, and we had enough bottle feeding charts at the time and this is where we began to really recognize like oh my gosh because we were actually taking data for an outside source. And so as we were taking this data we were starting to realize that one of the, one of the barriers in like we couldn't use a breastfed baby that was positive that had a positive urine drug screen. And, and so that was like that was a new thing to us because at that time, our drug screens weren't testing for suboxone. Initially, and so our first introduction to to MIT my first introduction to suboxone was really like seeing these babies going through withdrawal. I remember at first, being, you know, watching a baby going through withdrawal, and then us being like I don't know what's going on and when a baby goes through withdrawal you see you see similar, similar symptoms to, to like a low blood sugar so when a baby has low blood sugar for example when they're, they may have a diabetic mother they come out shaky they come out sweaty, you know, those type of things. And so we were trying to figure it out we end up sending a lot of these babies out to to a higher facility at first. And then we found out that that they were positive for suboxone and that was kind of our introduction like oh my gosh you know but the interesting thing was we didn't have access to suboxone in our community. So we were trying to piece this whole thing together and we were figuring out that a lot of our pregnant women were either getting suboxone off the street, or they were being referred out, they weren't being referred sorry. They were out accessing outside so so our introduction to this type of care was really backwards. So go ahead and go to the next slide. One of the one of the pediatricians who worked with us he started to back in 2012. Before then he did a chart review and he did. He created this little summary of his findings based on chart review and data. And he shared it with our administration and he shared it with different people, just to show you know hey there's something going on here. And it was shared up the ladder and this was a statement to the Senate Committee of Indian Affairs said in one IHS service unit approximately 54% of women tested positive for drug use while pregnant 52% of infants born tested positive for drugs. This realization that elicited a response, you know, and for us, learning, learning about, we had to number one learn about what is the box zone. How do we take care of these babies. And at the time there wasn't a lot of guidance, and we were really digging and asking for guidance and I remember we had IHS, the internal ACOG review people coming into our facility, and we and we were just really saying, are we what you know, this is what you know, and this really elicited a response because not only is it us as healthcare providers trying to come up with a plan and how we're going to respond to this but it was also us responding to families, because they're, you know, when there's such a high rate of people being flown out for reasons you start to hear. You start to hear why in the smaller tribal communities. And so, so we wanted to try to be in front of it but that's kind of where things got tricky, because the community begins to whisper in the community begins to respond. And so, there was several there was all kinds of crazy responses that time I'll go to the next slide. I remember there was, there was, you know, Facebook, there was several tribal communities that were putting out Facebook messages, telling people that, you know, releasing this is an example of one tribe this wasn't my tribe, but there was a tribe. Back then that was releasing laws or, you know, segments of their judicial system that was saying you know this is a crime, and this is what we're going to do. And, and it was, though we want to respond. It's important for us to really think about how we're responding. I mean it's already hard sometimes for women to come in and get prenatal care. And when you scare them and you say hey this is going to happen to you. They're not going to come in for prenatal care, and our whole, our whole goal is to prevent mortality. And we just really had to really think about, you know, moving together in productive ways, and so our community really took the approach of, no, we're not going to do that we need to work with. We need to work with each other. And we can't threaten them because we want them, we want pregnant women to access prenatal care. Next slide. So, our community and like the nurses that I worked with and my nursing, the supervisors and our admin, we were really working together to identify interventions. They created a coalition at the time it was called Obstetric and Neonatal Advocacy. We were wanting to create awareness of what's going on regarding our services, and really create, create a process of how that might work. So one of the processes that we really, we really reached out to, to our CPS system, you know, our internal tribal CPS system to say hey we're trying to support these women, how can we, we do this in a way that, you know, with less harm and more care. And so we were able to create a system and, you know, and work together in a way that, that that was helpful. I'm trying to think of some other things that we did at the time, but just really, just really creating a space for people to feel comfortable in accessing services. Go to the next slide. Since then, you know, and then that was really just our experience. Since then there's been tons of like amazing resources that they've created, and it just goes to show the response, you know that this, this was happening then but since then, a lot of our our healthcare leadership really responded and they gave us wellness plans, they gave us, you know, resources and, and, and what we could do, you know that what we can do and I think just for me personally it just inspired me to, to pursue more education because I really wanted to learn more about how I could advocate, and how I could teach. And I know somebody, I just saw somebody say IHS has supported Suboxone. So it's interesting because it does, IHS supports Suboxone itself, but not every community has that implemented and every community is very different in how they implement that and that's it's a whole different talk, but it is, it is, and I'm glad to see how I'm glad I'm so happy to see like just the growth that we've had, you know, from this like kind of assault, I guess that we've had at the moment in creating these these responses and these guidelines. Next slide. So I won't go into too much about about neonatal opioid withdrawal, but I did, I did want to show you guys the Finnegan scoring tool. This is a tool that we use when we were providing care to, to babies that were at risk for withdrawal. And this was really a good tool for us to, to educate moms. So say if a mom is at risk or is using opioids or maybe is on Suboxone, we do gotta let them know that their baby is at risk for withdrawal symptoms. And when a nurse comes in and is coming in to assess your newborn, this is what they're looking for. And it really gives some ownership and some control to the mom. And it brings it back to the mom so to understand what they're being, because a lot of times a mom's first thought is like, oh, why are they always in here checking on me? Why are they always, what are they doing? And sometimes that gets lost in communication. So really taking the time to prepare the mother in like, these are the things that may happen. And these are the things that nurses and healthcare providers are looking for when they come into your room every two to four hours or whatever your guidelines state. So I think that's really important and just really giving people the empowerment when they're taking care of their newborns. Next slide. So again, this is just another resources that were developed since that time. And this was actually developed a while back, but just recommendations to American Indian, Alaska Native pregnant people. And I just wanted to share how important education is and how important prevention is and really getting that out there. And we know it's available now is the important thing. We know that these resources are available to us. We know that Suboxone and opioid use treatment is available. And for me, it's exciting. It's exciting. I love that I can look and see that these resources are becoming available. But I think some of the barriers that we do face is implementing them in a way that supports and reduces stigma. And so, you know, really thinking about these recommendations that are out there and using them as educational tools for our communities really does help and support people accessing to care. So that brings me to the close of my presentation. And I'm really happy to share just the story of growth and the story of how we can support each other and support pregnant women and families. Thank you. Thank you, Heather. Wow, what a very emotional story for those of us that are touched by this topic. Because I think, like you said, in our rural communities, we're all impacted to some degree by any one of our relatives or friends, even our community members. You know, it stops you. And to be able to have your experience and the growth you talked about, you know, that's something that we need for everyone. And we're at that, we're on the crossroads. And so what a powerful presentation. Thank you so much. I appreciate it. So our next presenter, and this is our share out, I'd like to introduce Dr. Charlene Ramirez. And Charlene is also an enrolled member of the Blackfeet Nation in Montana. And she serves today as a clinical professor at Montana State University in the College of Nursing. The majority of her career has been working with indigenous patients and indigenous communities. And so she herself was at the Blackfeet Hospital. And while she was there, you know, her experience is gonna be similar to Heather's, but she worked to develop committees for the quality of care, provided a lot of training at that facility. And then as a part of that, she served as the coordinator for a project called the Baby Friendly Initiative. And with that, in 2014, the hospital received designation from that initiative. So welcome Charlene. Hi, thank you. Like she said, I did work with Heather. We worked together when we were in Browning. I'm currently still practicing as a labor and delivery registered nurse at one of the urban hospitals here in Montana. I've been doing obstetrics for almost 16 years now. I am also assistant clinical professor at MSU Bozeman. I did finish my doctorate this last summer from the University of North Dakota. And my goal was to become a professor so that I could recruit more Native American into nursing because I just feel like we need to take care of our own people. And so we need more of us out there and we need to be more available so that we can help flourish in our indigenous communities. When I did work at the Blackfeet Community Hospital that kind of led me to where I am today is that like they said, I was tasked with coordinating the Baby Friendly designation. And as Heather mentioned during this process, it became apparent that we had a high rate of substance abusing moms. So as nurses, our thought was how can we encourage them to breastfeed when they're using drugs? And so we reached out to larger hospitals, which was mainly Benefits in Great Falls. We reached out to them and said, what do you do? Because like she said, we were just reaching out for resources. How are we gonna find a way to help these women? And then that helped us determine what drugs were not compatible with breastfeeding, which ones that we actually could let them breastfeed on. And it just kind of helped solidify that whole process for us while we were in the hospital. Because as nurses, we just couldn't ignore this glaring problem. The IHS wanted us just to become baby friendly, get that going. But we had this other problem that was just glaring to us that we had a high rate of substance abuse moms. And we need to say, how are we gonna help them? We can't just focus on these breastfeeding moms. We have to focus on how are we gonna help both sets of moms coming up? Like Heather mentioned, we started some committees. We had an internal one and we had a community committee, which was Well Moms, Well Babies. And we just took all the resources available on the Blackfeet Reservation and we brought them all together. And we said, let's bring these all together. Let's collaborate and let's connect every pregnant women who's using substance abuse with the services that are available on our reservation. Let's bring all this together so we can hope for the best, the safest, healthiest outcome with a healthy baby after delivery. And then we didn't just stop at delivery. We said, we need to take care of them afterwards too. We need to continue following them. So the following case study just kind of represents a scenario which contains a pivotal moment for the pregnant individual. And this is the moment where healthcare providers could implement interventions that would be beneficial not only to the pregnant women, but also to the unborn baby and the partner and the families. So we'll just use initials BW. She had presented to the emergency room. Oh, sorry, next slide. She had presented to the emergency room complaining about a headache and abdominal pain. She stated she has not had a period in over five months and thinks she may be pregnant. So the ER provider consulted with the obstetric provider and a pregnancy was confirmed by ultrasound. So at this time, instead of continuing in the ER, they send her to an OB triage area. And the benefit to that is because we can do a further evaluation. So they go to the OB triage. She reported she did know she was pregnant, but she had not received any prenatal care. And they were estimating she was probably already like 32 weeks pregnant. So she said she was very worried about her baby and she was very cooperative during the assessment. The OB provider asked if she's agreeable to obtaining prenatal labs, a urine drug screen, which is common when you haven't received any prenatal care because we're just trying to figure out why did you not come get care and a comprehensive ultrasound. The patient did give consent to the urine drug screen, but did not divulge any additional information. And one of the points I like to make is it's very important that we obtain consent from the pregnant woman before doing any type of screening, including urine drug screening. And this is because this testing in pregnancy and at delivery can have enormous consequences for the birthing persons and their families. And so we don't like to surprise them. They know they're using drugs, but the rest of the family may not know. And so we just want to make sure we're being a team at this time. Like we said, we don't want to cause mistrust and if we take their urine, go test it without their knowledge and then come back in, we just broke that trust. And in order to have a healthy outcome, we need to keep that trust there. So she went ahead and did the urine drug screen, which showed she was positive for opioids. So the provider reviewed these results with the patient. The patient was very tearful, stated she didn't want to use, but she felt so ill when she stopped taking the pills. She expressed concern for her baby and asked if the baby will be okay. So next slide. So after we let them know what their urine drug test is, now what do we do? Now we could just say you're positive for drugs and this happens a lot. We just say you're positive for drugs. You shouldn't use them anymore and just send them out the door. And that's not what we should be doing. We should be helping them at this point. We'll be asking them, do you want to seek treatment for your opioid addiction? This patient was interested, so we help enroll them into a MAT, medication assistance program. And then we provide education about the facility protocol and offer support. So I'm gonna talk about that after this next slide. So this slide, I like to use even as a professor, I use this slide all the time, because when you have somebody who is not having their physiological needs met, which is like food, water, and warmth, you can't move forward. So if a woman is using substance abusing and some of them aren't able to get their food and water and warmth, maybe they're house hopping, maybe they haven't connected with any resources right now, we need to address all of those needs before we can even head towards treatment or we can head towards helping them through this, because the human needs are important to help the body function optimally. So our body doesn't function if our physiological needs are not met. So we need to address these. And once these needs are met, then the individual, we can move forward and do the safety and security where we can say, okay, we have your basic needs met, let's find you a safe place. That's when our committees collaborated and we worked with WIC, SNAP, TANF, Medicaid, we would get with the social workers or the nurses did a lot of this work also, and we get them connected with this so that we could get them food, we could get them hopefully start working on shelter at that time, and then we could slowly move up this. But we always have to remember if a person's physiological needs aren't met, they can't move forward. And that's what sometimes happens why you'll be like, well, we gave her all these resources and she still isn't trying to get treatment and it's because it's so overwhelming at the time for her that she needs help getting some of this set up. And so as a group, we decided we would walk them through all of these steps. Next slide. So we had a protocol in place for pregnant individuals that are addicted to opioids and other substances. So what we would do is what we did in this case is they go to ER, terminally pregnant, send them OB triage. We'd get all their prenatal labs so that way we know where we were starting to make sure there was no STDs, there was no other glaring issues that were occurring during the pregnancy. And then that's when we'd arrange for social work consult. And we did this all in the triage before we let them leave. We got all this set up so that before they walked out of our facility, they knew that they had all this stuff ready to go. And so they didn't have to worry about going from building to building to building to get all this set up, making phone calls. We did all of it for them. We made all these appointments for them. If they needed to, we'd arrange a ride. We'd schedule their next prenatal visit. We also completed domestic violence screening. And we'd refer to treatment programs at the time that Heather and I were up there. There was actually, were not very many treatment programs available. I'm not sure, I don't think it has changed that much as it even to this day for pregnant women. A lot of facilities get very nervous when they have to take a pregnant individual. And because they don't see the, they see the pregnancy, not the individual. And so we just have to work on letting them see the individual and knowing that that pregnancy is part of it, but they need to see that individual. So even as the place where I work at, when they go to the treatment facilities, if they can make one little complaint about pregnancy, they send them to the ER. So, you know, that's one of the issues and there's only so many beds available. We at the time also would have the patient sign a release of information, especially if they decided to do a medication assisted treatment. And that was, we worked with a provider that was in Helena when Suboxone first came. And we, they signed a release from there. They signed a release with us so that we could coordinate our visits. And so we'd make sure that they were using the medication appropriately, that they're seeking prenatal care. It was a wonderful setup that we had up there. We also discussed with the patient about withdrawal effects that infant would have after birth. And then we wanted to create a supportive plan for the patient to encourage your patient to identify support person who will be there for her during pregnancy and birth and plus postpartum so that they had a resource available. So they weren't going home alone if they were taking a baby home. I think Heather kind of touched on the side effects of what the babies would exhibit after they had the baby. So next slide. As a nurse, I push this all the time as education. We need to make sure we keep everybody educated. We need to educate them on what their baby's going to experience. We need to educate them how to develop the supportive plan, who they can reach out for help. And I have actually told people too, they're like, well, I don't have anybody. And I'm like, well, when they said, what am I going to do when I come in to labor? And I was like, your labor nurse is going to be your somebody. So as labor nurses, we step in and we're that extra person for them. We want to encourage them to, we want to educate them on the effects your baby will have because this is really important because that way they know what's going to happen after birth like Heather had already touched on. I didn't know, but when she was touching on that, she touched on pretty well on how, what the baby's going to exhibit and then what they're going to exhibit after birth. And then we want to talk about our facility. You know, what are they going to do in the hospital? And when we were working with CPS, we tried to, we actually called it, instead of the Child Protective Services, we called it Family Services because we don't always want to look at CPS as negative because they're really there to keep the child safe. And so we try to refer to it as Family Services saying these people are going to be here to help keep all of you safe during your pregnancy and after when you go home with the baby. And because their ultimate goal is to reunite the entire family. So that's all I have. Thank you, Charlene. Thank you very much. I appreciate that. And I have a couple of ways that people can ask questions. We have them, if you entered them into the chat box, then those will be read for you or you can raise your hand and open your microphone. And with that, I'll ask care of, she'll bring any questions forward for the presenters. Sure. So there was two questions asked a bit earlier in the presentation. Both were answered. The first was, what was the name of the video and is it accessible? And Chelsea did provide a link to the full video in the chat. And then the second question was, when did IHS approve Suboxone for MAT? And that question was also answered. But if there are any other questions regarding information around that, please feel free to either type in the chat or raise your hand and you can unmute. Was this the question regarding MAT or in IHS approval? Yes, Heather. So I know you touched on it a bit. Yeah, I touched on it a little. Yeah. So I, you know, the good thing is MAT is accessible. Is accessible. It is being provided. We are creating avenues in different systems. The issue, I don't know if I would see it as an issue, is not every community is at a place where they're, you know, where they're offering. You know, I went home, like, in the community that I work in, they've been providing MAT and Suboxone for, geez, since 2010, 2011, there's been a provider at the tribal health who's been doing it in an outpatient setting. But as far as like, you know, an MAT program, you know, we were able to develop that in California at the tribal clinic that I had worked at. But I know that there are communities that really struggle with that because of stigma from their tribal leaders, from their community members. Because, you know, like mentioned, when I shared that video, if you notice that, you know, the mom who said, my daughter's addicted to Suboxone, people in tribal communities still believe that Suboxone's the drug that their family member is addicted to. And you hear that a lot, especially, you know, even amongst my friends, when I was explaining to them, you know, the work that I do and, you know, with MAT, they're like, well, why would they do that? It's just giving them some, you know, you hear a lot of those stigmas that still come up and that we're really trying to use education to help develop those resources and that access. So I do commend, you know, IHS is providing that access and is really leading that. But, you know, the uptake of places are definitely in different steps. So, you know, I just, I encourage all communities to figure out who's leading that movement in your organization to, you know, really reach out. And if there are barriers that are being identified, reach out and try to find how, you know, what those barriers are and how you can overcome them so that people do have access within tribal communities. And that's really, you know, that's really what, you know, organizations, TA support, like the ORN, for example, that's really what those are for because sometimes you do need somebody to come help you with that message. So, you know, it's just a quick little plug for the Opioid Response Network and all of these, you know, support systems that we have because the support is there and we can overcome these barriers. We just need, you know, a little bit of education to really support that narrative. Thank you, Heather. What a great lead-in to our next, do we have any other questions? Anyone? If you do have any- I see comments in the chat box too, that's fine. Yeah, feel free to put them either in the chat box or raise your hand and we can unmute you. Okay, I'd like to invite Francesca, if you could come back on and give us a little overview of ORN. Thank you, next slide, please. So yeah, Heather, that was a great lead-in to what I'm gonna talk about right now. So, the ORN can support you in so many ways, dealing with pregnancy, dealing with childbirth, and so many ways dealing with pregnancy and the need in our community. One back, please. So, a few ways we can help is by providing training on how to care for pregnant women who use substances, consultation and review for policies and procedures related to maternal SUD treatment, and training on ICWA and the intersection of ICWA and SUD. Next slide, please. So again, we're here to help by submitting a TA request on our website. The link will also be provided in the chat. Okay, thank you. Thank you, Francesca. And so in closing out today, I have a few slides that I'm going to go through here. And is there anything in the chat that we'll start to share with you? But this is our next webinar. And as you can see, it's going to be on the 30th of May from 2 to 3.30 Eastern Time. And the title is Nurturing Brilliance of Native Youth Community and Cultural Connection as Prevention is our next webinar. Going forward. Next slide, please. Through July of this year, you'll see our May 30th webinar and then again, June 27th, whole native SUD treatment care examples. And then in July on the 25th, holistic SUD treatment care examples will be our next webinars coming up. And then we have our survey link slide. Next slide, please. And we'd like we have a link in the chat box, you can register for that webinar. And then this QR code will also be placed into the chat box. Thank you. Thank you. And then in closing out today, these next two slides we have our resources available for you. And again, there's there's a lot of information here. And we'll put some of those over here in the chat box for you. And again, I just in closing today, I just would like to thank you so much for your time to our presenters, both of you. What a stellar performance. Awesome, awesome work in the community. And then to have this kind of work lead you in your career going forward is is really inspiring. And thank you everybody on the workshop on the webinar today and we look forward to seeing you again on the next one. Thank you.

webinar

pregnant individuals

substance use disorders

physiological needs

treatment plans

support

education

healthcare providers

MAT

tribal communities

Opioid Response Network (ORN)