"There are only so many fires you can put out": nonprofit structural constraints on service delivery for pregnant and postpartum women who use drugs in Appalachian North Georgia

Abstract

Drug overdose deaths for low- and no-income women during pregnancy and the postpartum period are on the rise in the United States. Unfortunately, health and social services for pregnant and postpartum women who use drugs (WWUD) are lacking, especially in rural areas. In this qualitative study, we explore provider perspectives on the service provision terrain for pregnant/postpartum women who use illegalized drugs in 17 North Georgia Appalachian counties. We conducted 35 one-on-one semi-structured qualitative interviews between October 2023 and May 2024 with governmental and non-governmental organization employees who held frontline and/or leadership positions in these counties. We used thematic analysis to identify patterns within and across transcripts. Our guiding conceptual framework builds on existing perspectives on the "nonprofit industrial complex," and uses the risk environment model to highlight meso-level obstacles that hinder WWUD from experiencing a healthy pregnancy and postpartum period. Our findings indicated that service providers-most predominantly working in 501(c)3 community nonprofits-struggle to meet the complex needs of pregnant/postpartum WWUD. They reported how the bureaucratic entanglements and fragmentations distinctive of 501(c)3 community nonprofits both impede holistic services and necessitate collaborations to piecemeal vital services together to serve this population. Our findings suggest that the multitude of struggles rural and low-no income pregnant/postpartum WWUD in North Georgia face cannot be addressed adequately through current siloed single-issue community nonprofits, regardless of how well-intentioned. These findings underline the importance of meso-level investigation of the risk environment into institutions like nonprofits tasked with assisting this population.

Keywords: Community nonprofits; Postpartum; Pregnancy; Qualitative studies; Service provision; Substance use.