Based on frequency, richness, specificity, and emotionality of the responses, seven main themes related to mother's urges to use illicit substances were identified. We present the themes in an approximate chronological order: Maternal Childhood Bond, Pregnancy and Postpartum Attachment, Birth Experience Support, Department of Child Safety (DCS) Involvement, Breastfeeding, Mental Health, and Recovery Plan (see Fig. 2). Aliases are used in reporting the results to protect the privacy of participants.
Maternal Childhood Bond: “It was Like How, How I Want, How I Want to Be with my Kids”
Mothers across categories described their childhood bonding experience with their mother as a motivator for creating a positive relationship with their newborn, however, there were differences in the perceived impact of their childhood attachment. For MNUs, many described that they did not have a positive bond with their mothers as children, but this motivated their desire to create a better bond between themselves and their infants. For example, Jane, aged 32, MNU, explained,
The fact that my mom left me when I was little, I think that made me want to be with my kids and be a better mom. Because I could never imagine leaving my kids. Every kid deserves to bond with their mom and be with their mom and be loved by their mom.
Samantha, 22, MNU, also explained,
I don't have that kind of bonding or that kind of relationship with my mom… She wasn't caring or nurturing or anything like that, while growing up. So, I try to do better and be the best that I can for my kid. I learned not to be like my mom. I learned patience is a key for parenting. Time and attention is what matters the most when having a child. And being a positive role model is what they need. But [my mom], she definitely strengthened those traits about me.
On the other hand, some MNIUs and MUs described a close childhood bond with their mothers and that this motivated them to want to create the same type of bond with their babies. Lara, age 30, MU, explained her maternal childhood relationship, stating, "It was close… My mom was on drugs my whole life… but she never failed to take care of me… I never had to work for anything." She went on to explain that she wanted the same with her baby, saying, "I can say from dealing with my own mom, [I hope my baby and I] establish and get that good grounds for communication from the beginning." Priscilla, age 26, MNIU, also explained, "I'm so grateful that my mom raised me because she showed me like how to be a mom and how like to take care of my kids." Similarly, Ana, 35, MU, explained, "It was, it was, it was really good. As far as I can remember you know, um, it was like how, how I want, how I want to be with my kids you know."
Pregnancy and Postpartum Attachment: "I didn't Talk to my Tummy a Lot…that was During the Time When I was Still Kind of Upset"
In general, mothers in all three categories described the news of their pregnancy as being unexpected or shocking and described feeling like they did not know what they would do. For example, Kristen, age 32, MNU, explained, "[I was] shocked cause I already had three and didn't plan—I didn't plan on anymore." Kiana, 34, MNU, described, "I got pregnant. I was like, this wasn't part of the plan… I was shocked to say the least. I was surprised. I wasn't expecting it." MNIUs described similar expressions of shock. However, in addition to feeling shocked and unprepared for the pregnancy, MNIUs were more likely to report feeling upset and scared upon learning about the pregnancy. Alicia, 27, MNIU, stated, "I couldn't believe it… It made me nervous. Scared. I didn't know what to do or what to expect really, you know?" Mayra, 21, MNIU, explained, "honestly, I was really sad and depressed, I didn't expect it—having another child." Sarah, age 32, MNIU, also stated, "I was very surprised and scared… I was not planning on having a baby yet." While MUs also described feeling shocked and scared, they were more likely to find out about their baby late into their pregnancy. Lara, 30, MU, explained her reaction to finding out about her pregnancy late, stating, "I cried because, uh, I didn't find out till I was 6 or 7 months… There wasn't even time to develop all of those emotions and place all of those emotions." Ava, 27, MU, stated, "I didn't find out until pretty late, like believe it or not… I didn't know. I was like 20 weeks."
In addition to feeling unprepared, mothers' connection to their baby during pregnancy was also prominent. Among MNUs and MNIUs, there was no mention of having difficulty developing an attachment with their baby during pregnancy. Mia, 22, MNU, described the bond she felt during her pregnancy, saying, "It's gotten stronger, um like when I was pregnant, I would talk to my stomach, I'd be so happy you know." Similarly, Kiana, 34, MNU, felt an attachment with her newborn during pregnancy. "I think he always has, cause like even when I was pregnant, when I would cry, or I'd be sad, he'd move. He'd comfort me." However, several MUs explained that they did not have a strong attachment with their newborn during pregnancy. Lara, age 30, MU, described, "I-it was rough in the beginning because I felt like we weren't connecting. And that was when she was in my stomach… I didn't talk to my tummy a lot you know and that was during the time when I was still kind of upset." Aaliyah, age 32, MU, also described, "I think that at first, when before I had the baby… I was really, really scared to get attached because… I didn't know what was going to happen with DCS if I was going to like keep my children."
Mothers more often talked about connecting with their babies once they were born, particularly through skin-to-skin contact. Michelle, 41, MNU, described that "Especially with the skin-to-skin, [she felt baby truly started to bond with her] like instantly." Priscilla, 26, MNIU, described, "I'll lay him on my chest, you know, skin-to-skin because they recommended that and I feel maybe a little stronger bond… because when I lay him on my chest skin-to-skin he'll always lay his face a certain way, like right on my heart." Rachel, age 26, MNU, described, "The skin-to-skin, and with her going through like the withdrawals and stuff, she was really dependent on me I guess for comfort and everything. So that's when it, when the bond really started."
Many mothers described using babywearing to continue their bonding relationship with their newborn. For example, Aaliyah, age 32, MU, explained, "It kind of imitates skin-to-skin even though it's not skin-to-skin. I think it creates that bonding, especially for a dad too. It gives him that experience." Similarly, Olivia, 36, MU, said, "…it [babywearing] felt really secure, you know… I felt the closest probably when she was… I was wearing her… like putting her in the carrier was a moment when I felt like my baby truly started to bond with me." Sarah, 32, MNIU, described how babywearing substituted for her struggles with breastfeeding by giving her a way to stay close to her baby, saying,
I think most people know like [breastfeeding is] such a special connection with your child… [so] I was so sad that I couldn't [breastfeed] but we're still wearing the carrier… I would just wear her most of the time, just get her to bond to like just to have that contact… Yeah, it really helped substitute for the lack of nursing.
There were no differences across mothers in babywearing or skin-to-skin contact and bonding with their infant once the baby was born.
Birth Experience Support: “I Had to Experience Everything by Myself”
In general, MNUs described how having support figures, such as a partner or family members, present during their birth experience made their overall birth experience better. For example, Kristen, age 32, MNU, described, "we had a lot of support and it was very peaceful and everything completely just worked out." On the other hand, MUs explained that they missed having any social support. Olivia, age 36, MU, explained, "I would have wanted it to be different, you know, if I had my choice… I would have liked to have my partner there." Similarly, Celia, age 36, MU described missing out on the support of her partner at the birth because of the quick onset of labor, "I went in an ambulance by myself because the kids were there at the house…it was the worst experience of my life." MNIUs did not talk about support figures as part of their birth experience.
In addition to partner support, participants described the hospital staff's support, or lack of support, as impactful to their overall birth experience. MNUs generally described feeling accepted while at the hospital. For example, Lucille, age 32, MNU stated,
Being on methadone, you can like come across people who don't understand or don't get it and [the hospital staff] were all very respectful and patient and... not judgmental at all. They were very helpful, so it was a really, really good experience.
Conversely, MUs talked about the stigma of recovering from a substance use disorder. Olivia, age 36, MU, shared, "There's a definite treatment that was like, probably you know, because of my history. So I feel like I was treated overall like a dumbass. I just thought they were gonna like take my kid and pretend like everything was gonna be okay." This perception was echoed in some participants' experiences that their birth pain was not perceived as valid. For example, Celia, age 36 said, "I just wanted medicine because I was in so much pain and they wouldn't give it to me and I was screaming and yelling and they're like, telling me they're like, calm down because I was scaring people but they didn't understand. They didn't know what was going on inside my body like my uterus tore. When [the doctor] opened me up she goes, 'oh, that's why she was in so much pain'."
Department of Child Safety (DCS) Involvement: “They were Involved When She was Born Because I was on the Methadone”
All the mothers in the study faced potential DCS involvement. However, most MNUs did not have any DCS involvement after the initial interview. Michelle, 41, MNU, explained how the potential involvement of DCS impacted her emotional well-being in her response to the interviewer’s question,
I felt nothing to look forward to…I would say sometimes and a lot of this in the last week is more situational with the DCS meeting. So now that that’s past and you have a resolution in a sense, I feel a lot less stressed out and [less] anxiety. I feel like I can enjoy him now…Everything has been revolving around this DCS and not knowing until yesterday…and the threat of losing him.
In Michelle’s case, her mother was identified as the safety monitor for the next 30 days, until the baby had no levels of THC: “Once that’s at zero, then my mom is able to go. But we’ll be taking intense in-home services. So, I’ll have a person from two different programs come out.”
For some MNIUs, DCS became involved within the initial weeks following birth. For example, Mayra, 21, MNIU, explained that her baby was placed into DCS care at 9 days old, and "I see her three times a week, like 2 (h) each visit." However, almost all DCS involvements initiating at birth were found with MUs. For example, Olivia, 36, MU, discussed how her feelings of attachment have changed due to her involvement with DCS. "I felt like because I haven't had my kids for a while, they haven't lived with me for a while. And it's like the longer they're away from you, the less you feel like a mom."
Breastfeeding: "Breastfeeding isn't All What People- Like- Make It"
Mothers with No Urges (MNUs) described a positive breastfeeding experience with their infants. For example, Jane, age 32, explained, "yes, [I breastfed] for 2 to 3 months, I wanna say," and had few difficulties with breastfeeding. Furthermore, even among MNUs that did not initially plan to breastfeed, some were still breastfeeding successfully at 6 months. In contrast, a common pattern for MNIUs was that many breastfed successfully for only a short period of time and often had difficulties in their breastfeeding experience. Sarah, 32, explains, "she only breastfed for 2 months, and it was a fight the whole time… So, I hardly breastfed her, which was sad because I loved how much bonding it was and how much me and my first daughter bonded while breastfeeding." Similarly, Alma, 28, MNIU, explained, "no, I don't breastfeed. I did in the beginning, but I didn't make enough." Most MUs did not breastfeed or described significant struggles with breastfeeding their newborn. Joanna, age 29, describes the difficulties she faced trying to breastfeed, explaining, "I can't breastfeed, which sucks… He wouldn't latch, so I pumped but it wasn't enough to fulfill him… eventually, I just couldn't make enough at all. It was so sad."
Mothers in all categories described feeling sadness and frustration about their experiences when difficulties with breastfeeding were present. However, disinterest in breastfeeding was only displayed in MUs and was not seen in MNUs and MNIUs. For example, Judith, age 31, MU, described, "even though they did recommend it [breastfeeding], I just personally, I just chose not to." Despite these patterns, mothers in all three categories made statements about breastfeeding as a significant source of bonding between them and their newborns.
Mental Health: “Sometimes Hormones and Pregnancy Like Mess People Up”
Differences in participants’ perceptions of their own mental health emerged as well. Specifically, the experiences of MUs were noted by explicit statements of challenges with mental health. For example, at age 33, MU, Natalie stated,
Often I have felt downhearted and blue… I'm just disgusted. I'm just to the point where I lost so much weight, where I don't even care like it doesn't bother me. I look sick. I don't really care anymore. I know what's going on with me and I'm just sad you know. I'm just sad [baby crying].
Lara, age 30, MU, also explained, "My postpartum [depression] when I got home was a little, a little bit hard at first… [the baby’s] so far away." Similarly, Joanna, age 29, MU, stated, "The postpartum [depression] has really taken a toll on me." Mary, 21, MU felt similarly and stated how critical it was that she received help:
Mary: I wasn’t expecting it [to be hard] at all, like I’d want to kill this dude sometimes…that’s not a lie, especially if I didn’t take my medication. I had no idea about postpartum, I had no idea.
Interviewer: So you’re experiencing postpartum depression?
Interviewer: And maybe postpartum anxiety?
Interviewer: And then it was hard on your relationship?
Mary: It was…there were times when I wouldn’t take my medication because I was getting mad, like why do I need this to function, I shouldn’t have to take this. It took me a while to get that understanding of what was going on, I would get really manic without it, wouldn’t eat, wouldn’t sleep, so at first it was very difficult to deal with and I was feeling extremely alone with it. But now, it’s like a complete 180 you know. I make sure I take my medication every day.
In contrast to MUs, explicit statements regarding mental health were rare among MNUs and MNIUs. Georgia, 26, MNU, explained how she copes with her mental health:
I struggled with PTSD, anxiety, depression, and I've learned so much grounding techniques and self-soothing and honestly just living differently…you think you have all those problems, but a lot of it is drug or detox induced so after you’ve been through all that and you have some really good amount of time—like it’s been almost three years for me now, so it’s nice—a lot of those things don’t exist anymore...
Alma, age 28, MNIU, also stated, "I have plenty of purpose."
Recovery Plan: “Relapse Could Be Around the Corner, any Day”
Finally, mothers' treatment and perceptions of their recovery appeared to be a meaningful factor that varied across each category of mothers. Most mothers across categories indicated they were prescribed methadone as pharmacotherapy for their substance use recovery. Suboxone was more commonly prescribed to MNUs (N = 10) or MNIUs (N = 6) compared to MUs (N = 26). See Table 1.
Most mothers across categories described their baby as a motivator for working towards recovery. However, there were some notable differences in how mothers in each category articulated their steps to recovery and the role their baby played in recovering. MNUs made slight adjustments in their lives to stay present for their baby and prioritize recovery. For example, Kiana, age 34, MNUs, described, "I look back and I think of—all the time that I missed… Just little things that I missed. That I didn't get to see for the first time, so, I try not to miss anything now… I want to see everything." Georgia, age 26, MNU, also advised, "keep working on your recovery and love your baby and you know, if you're feeling bad reach out and just keep going, you know?".
In contrast, MNIUs and MUs described their approach to recovery as a change in their thought process. For example, Priscilla, age 26, MNIU, explained that having her baby decreased her urges to use substances. It was hard, you know but- especially after having him, it’s, it’s pushed me even further away from it… like when you were asking me about the urges…it's more of the urge not to ever want to touch it again." Aaliyah, 32, MU, talked about what she has learned after having her baby, stating that "I've learned that the mistakes I've made, they're not worth losing my family over. Like referring to my use… [I learned] not to take your baby for granted because it's a privilege to be a parent."