TOPLINE

Advanced practice maternity providers (APPs) frequently experienced ethical conflict when making decisions on drug testing and child welfare reporting for pregnant and postpartum patients with opioid use disorder (OUD). Providers working across inpatient and outpatient settings, those from the Southern US states, and midwives reported greater ethical conflict, whereas those with children reported less.

METHODOLOGY

• Researchers conducted a cross-sectional survey between July and December 2024, involving 171 APPs (midwives, nurse practitioners, and physician associates; mean age, 43.3 years; 81.2% White individuals) across the US who had cared for pregnant or postpartum patients with OUD in the past 6 months.
• APPs completed an online survey adapted from the Ethical Conflict in Nursing Questionnaire — Critical Care Version, determining exposure to and the types of ethical conflict experienced across 19 clinical scenarios regarding drug testing and child welfare system reporting.
• Clinical scenarios were grouped into four domains — beliefs and judgements, rights and autonomy, policies and laws, and structural factors — to differentiate the level at which the ethical conflict occurred.

TAKEAWAY

• Providers reported the greatest ethical conflict in scenarios involving structural factors, particularly stigma from colleagues caring for pregnant and postpartum patients with OUD.
• Having children predicted lower ethical conflict (P = .01), whereas practicing in both inpatient and outpatient settings predicted higher overall ethical conflict (P = .026).
• Midwives reported higher exposure to ethical conflict than nurse practitioners or physician associates in scenarios that involved drug testing without informed consent, stigma from clinical colleagues, and institutional interests being prioritized over patient needs. Providers in the South compared with those in the Northeast reported higher exposure to ethical conflict related to fear of poor maternal outcomes if no drug test was performed, fear of child abuse or death if no child welfare system report was prepared and sharing of patient data with law enforcement.
• Moral dilemma was most frequently reported for scenarios related to beliefs and judgments, moral distress for scenarios related to rights and autonomy and structural factors, and moral well-being for scenarios related to policies and laws.

IN PRACTICE

“Assisting maternity APPs as they navigate difficult ethical decision-making for their patients, and support their patients’ capacity to parent, is fundamental to improving care to pregnant and postpartum women with OUD,” the authors wrote. These findings, they added “lay the groundwork for future exploration of this topic [ethical conflict] and, ultimately, the development of tailored interventions to better support these essential maternity providers as they care for women and their infants impacted by OUD.”

SOURCE

The study was led by Caroline K. Darlington, University of Pennsylvania School of Nursing, Philadelphia. It was published online on May 30, 2026, in the Journal of Substance Use & Addiction Treatment.

LIMITATIONS

The sample was homogeneous, consisting entirely of women, which limited the results’ generalizability to male providers or physicians who have different training, perspectives, and practice autonomy. The study did not account for patient-level factors that may have influenced ethical conflict. The type of ethical conflict variable was limited because providers’ specific decisions and exact sources of conflict were not explicitly identified. As ethical conflicts are self-reported, they may not represent real or actionable barriers.

DISCLOSURES

This study was funded by the Heilbrunn Family Center for Research Nursing at The Rockefeller University, through the generosity of the Heilbrunn family, and the National Center for Advancing Translational Sciences, National Institutes of Health, through The Rockefeller University. One author reported receiving financial support from the Heilbrunn Family Center for Research Nursing at The Rockefeller University. Rest of the authors reported having no relevant conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.