How States Can Expand Substance Use Disorder Treatment During Pregnancy

Most people who use drugs or alcohol reduce or stop their use during pregnancy, but those who do not may have an untreated substance use disorder (SUD) and could benefit from treatment.¹

Without such care, pregnant patients and their infants can experience a range of negative health consequences. Untreated SUD is linked to premature birth, low birth weight, and stillbirth.² Babies exposed to alcohol in utero can develop fetal alcohol spectrum disorders, which can cause a range of lifelong physical, behavioral, and cognitive impairments.³ In the United States, in utero exposure to alcohol is a leading preventable cause of birth defects and neurodevelopmental disability in infants and can be complicated by malnutrition, which is common among people with alcohol use disorder.⁴

If exposed in utero to opioids, babies can experience neonatal opioid withdrawal syndrome (NOWS), a group of withdrawal symptoms that occur at or shortly after birth. These symptoms can include tremors, decreased sleep, feeding difficulties, fever, and seizures.⁵ Few studies have examined the effects of NOWS later in life, but some researchers have linked the syndrome to an increased risk of developmental delays, mental health and behavioral health issues, learning difficulties, and vision impairments.⁶

Beyond the consequences of SUDs for babies, unintentional overdose is the leading cause of maternal death, outranking cardiovascular causes, hypertension, infection, homicide, and suicide.⁷ Among individuals with opioid use disorder (OUD), the risk of overdose remains elevated through the first postpartum year, peaking at seven to 12 months after delivery.⁸

To improve health outcomes, states should establish policies that integrate SUD treatment with obstetrics and gynecologic practice. Such policies can reduce barriers to treatment and may improve engagement with prenatal care, and evidence suggests that these models are associated with better maternal and newborn outcomes.⁹ The following examples illustrate how some states have put integrated care models into practice.  

The benefits of linking SUD treatment with prenatal care

Indiana and Oregon have successfully paired obstetrics and gynecologic care with SUD treatment. In 2021, Indiana Medicaid launched the Indiana Pregnancy Promise Program, providing integrated services to Medicaid-eligible women who used or had used opioids and who enrolled in the program during pregnancy or within 90 days of giving birth.¹⁰ The program was later expanded to include all substances. With funding from the Centers for Medicare & Medicaid Services and the Substance Abuse and Mental Health Services Administration, case managers coordinate care from healthcare providers and community resources and connect participants to medications for opioid use disorder (MOUD).¹¹ Participants can meet with case managers by phone or in person during pregnancy and up to 12 months postpartum.

Indiana’s program has had a measurable positive impact. Participants who gave birth between January 2021 and September 2023—a select sample of enrollees in the Promise program—received more postpartum care compared with a group of mothers who were not enrolled.¹² During the same period, the Indiana Pregnancy Promise Program also made more than 2,000 referrals for nutrition and health-related social services, including housing and transportation needs.¹³

In 2014, Oregon introduced Project Nurture, a coordinated care model for Medicaid beneficiaries that offers SUD treatment alongside maternity care.¹⁴ In addition to prenatal visits, Project Nurture sites provide SUD treatment at any stage of pregnancy, and mothers and infants can continue to receive services for up to a year postpartum. Sites offer MOUD, the standard of care for OUD,¹⁵ and some also offer contingency management, an evidence-based behavioral therapy that provides patients with material rewards for demonstrated positive behaviors. The intervention has been shown to reduce the use of stimulants including cocaine and methamphetamine, to increase treatment retention, and to improve adherence to prenatal care.¹⁶

To further integrate care, Project Nurture has also partnered with federally qualified health centers (FQHCs), which are community-based clinics that provide services regardless of insurance status or ability to pay. One Project Nurture site embedded an FQHC family medicine team in an SUD treatment organization, allowing prenatal care and specialty SUD treatment to be delivered on-site.¹⁷ The FQHC team provides prenatal and postpartum care to patients once a week, as well as ongoing primary care to families after birth.

Project Nurture has demonstrated positive outcomes for families affected by OUD. In Multnomah County, which contains the majority of Portland residents, the program was associated with a reduction in foster care by 8.3 placements per 100 births from 2012 to 2017 while foster care placement rates increased elsewhere in Oregon for babies born to mothers with OUD.¹⁸

Community-based providers are a valuable resource for underserved patients seeking prenatal care, with one study finding that 2 in 3 FQHCs provided on-site prenatal care in 2024.¹⁹ Similarly, a Chicago community health center used private grant funding to integrate prenatal and OUD care. Led by a certified addiction registered nurse, the program partnered with local lifesaving strategies organizations (commonly known as harm-reduction organizations), substance use treatment facilities, and community outreach programs to identify patients with OUD or other SUDs and connect them to care.²⁰ According to the health center, 33% of all patients identified by the program and its community partners as needing OUD and prenatal services initiated MOUD. Overall, the program has shown meaningful success in establishing community partnerships to help serve pregnant people who use substances.

A community-based workforce can strengthen integrated prenatal and SUD care

Integrated care can be supported by community health workers, peer support specialists, and recovery coaches who help maintain connections between patients and their healthcare providers. For pregnant patients, this team can also include recovery doulas. This staff can offer physical, emotional, and informational support to patients in treatment and recovery.

• Community health workers provide support during and after birth. They can screen for SUDs and make referrals to treatment services, educate patients about the harms associated with drug use during pregnancy, and connect patients to health-related social service needs, such as financial assistance or transportation.²¹
• Peer support specialists have lived expertise of SUD and are themselves in recovery. They provide emotional, informational, and hands-on support to patients and, through their personal experience, build trust and increase connections to care and treatment engagement. Peer support services are associated with reduced substance use, and with treatment retention and better relationships with healthcare providers.²² Research also suggests that peer supports can reduce the risk of perinatal depression.²³
• Recovery coaches can also have lived expertise of SUD and receive training to support patients’ recovery goals. Through goal setting and accountability, recovery coaches work with patients over time to secure stable access to food and shelter, develop their education and problem-solving skills, strengthen their ties to family and community, and establish other foundations for long-term recovery.²⁴ The services recovery coaches provide have been shown to increase engagement and retention in treatment.²⁵ For example, perinatal peer recovery coaches embedded in the Moms Do Care program in Massachusetts, who serve as role models for patients and provide parenting support, are considered essential to recruitment and retention.²⁶
• Recovery doulas are trained professionals who can offer emotional support, help gather resources, and serve as health advocates for pregnant patients who use substances. Pregnant patients in OUD recovery have said that doulas reduce the stigma they face from healthcare providers and that the doulas’ emotional support helps their recovery process.²⁷ Staff at an opioid treatment program in Philadelphia reported positive perceptions of their patients’ doulas, noting that their support may have increased patients’ willingness to engage in prenatal care.²⁸

How states can strengthen prenatal and postpartum SUD care

To improve the health of pregnant patients and their babies, states should examine how their policies may help or hinder integrated pregnancy and SUD care. Policies can include using Medicaid and other state funds to support models of care that prioritize integration and coordination of prenatal and SUD treatment services; providing training and certification pathways along with reimbursement for nonclinical workers who support treatment and recovery; and extending Medicaid coverage from 60 days postpartum to 12 months postpartum.²⁹ In March 2026, Wisconsin joined 48 other states and Washington, D.C., in extending Medicaid coverage to cover enrollees and their children one year after birth.³⁰

State policymakers should also consider how their current laws may discourage pregnant women from engaging in care. For example, 24 states and Washington, D.C., treat prenatal substance use as child abuse or neglect or can use it as evidence of such, which deters pregnant people from seeking substance use care for fear of losing custody of their children, undergoing lengthy investigations and monitoring, or facing criminal charges.³¹ Researchers have also found that laws criminalizing prenatal drug use are associated with decreases in prenatal care and may reduce births in a healthcare setting.³² Punitive prenatal substance use laws, which can vary in severity, have been associated in some studies with a decrease in SUD treatment, delayed prenatal care initiation, and increased odds of neonatal drug withdrawal syndrome.³³

The best way to protect the health of babies born to people with an SUD is ensuring the availability of SUD treatment during pregnancy. Integrating SUD treatment into prenatal care, increasing access to a community-based workforce, and reconsidering the punitive measures that discourage SUD treatment can reduce stigma, increase care, and help mothers, babies, and families thrive.

Endnotes

1. Ariadna Forray et al., “Perinatal Substance Use: A Prospective Evaluation of Abstinence and Relapse,” Drug and Alcohol Dependence 150 (2015): 147-55, https://www.sciencedirect.com/science/article/pii/S0376871615001118. MacKenzie R. Peltier et al., “Licit and Illicit Drug Use Across Trimesters in Pregnant Women Endorsing Past-Year Substance Use: Results From National Survey on Drug Use and Health (2009-2019),” Archives of Women’s Mental Health 25, no. 4 (2022): 819-27, https://pmc.ncbi.nlm.nih.gov/articles/PMC9359119/.
2. “Perinatal Substance Use,” Ruta Nonacs, July 1, 2025, https://womensmentalhealth.org/specialty-clinics/perinatal-substance-use/.
3. “About Fetal Alcohol Spectrum Disorders (FASDs),” Centers for Disease Control and Prevention, Aug. 10, 2026, https://www.cdc.gov/fasd/about/index.html.
4. “Understanding Fetal Alcohol Spectrum Disorders,” National Institute on Alcohol Abuse and Alcoholism, December 2025, https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/understanding-fetal-alcohol-spectrum-disorders. Giorgia Sebastiani et al., “The Effects of Alcohol and Drugs of Abuse on Maternal Nutritional Profile During Pregnancy,” Nutrients 10, no. 8 (2018): 1008, https://www.mdpi.com/2072-6643/10/8/1008. Lynda J. Ross et al., “Prevalence of Malnutrition and Nutritional Risk Factors in Patients Undergoing Alcohol and Drug Treatment,” Nutrition 28, no. 7-8 (2012): 738-43, https://www.sciencedirect.com/science/article/pii/S0899900711004102.
5. Stephen W. Patrick et al., “Neonatal Opioid Withdrawal Syndrome,” Pediatrics 146, no. 5 (2020): https://doi.org/10.1542/peds.2020-029074.
6. Meghna Rajaprakash et al., “Neurodevelopmental Outcomes of Prenatal Opioid Exposure and Neonatal Opioid Withdrawal Syndrome: A Systematic Review From Birth to Early Adulthood,” Journal of Perinatology 46, no. 4 (2026): 509-18, https://doi.org/10.1038/s41372-025-02496-7.
7. Hooman A. Azad et al., “Overdose, Homicide, and Suicide as Causes of Maternal Death in the United States,” New England Journal of Medicine 394, no. 7 (2026): 722-23, https://www.nejm.org/doi/full/10.1056/NEJMc2512078.
8. Hooman A. Azad et al., “Overdose, Homicide, and Suicide as Causes of Maternal Death in the United States.” Jessica Frankeberger et al., “Opioid Use Disorder and Overdose in the First Year Postpartum: A Rapid Scoping Review and Implications for Future Research,” Maternal and Child Health Journal 27, no. 7 (2023): 1140-55, https://pmc.ncbi.nlm.nih.gov/articles/PMC10365595/.
9. Daisy J. Goodman et al., “Integrated vs. Nonintegrated Treatment for Perinatal Opioid Use Disorder: Retrospective Cohort Study,” American Journal of Obstetrics & Gynecology MFM 4, no. 1 (2022): 100489, https://www.sciencedirect.com/science/article/pii/S2589933321001841. Julie Seibert et al., “Integrating SUD and Ob/Gyn Care: Policy Challenges and Opportunities Final Report,” 2022, https://aspe.hhs.gov/sites/default/files/documents/c6b2ebd8dc8ca1f45ffcec6b9e6aacb3/integrating-sud-obgyn-care.pdf.
10. WISE Indiana, “Indiana Pregnancy Promise Program Evaluation,” 2025, https://www.in.gov/fssa/promise/files/WISE-IN-TO049-IPPP-EvaluationReport.pdf.
11. “Indiana Pregnancy Promise Program: For Pregnant Women,” Indiana Family and Social Services Administration, https://www.in.gov/fssa/promise/for-pregnant-women/. WISE Indiana, “Indiana Pregnancy Promise Program Evaluation.”
12. WISE Indiana, “Indiana Pregnancy Promise Program Evaluation.”
13. Indiana Family and Social Services Administration, “Indiana Pregnancy Promise Program Annual Report,” 2023, https://www.in.gov/fssa/promise/files/IPPPAnnualReport2023.pdf.
14. “Project Nurture Engages Pregnant People With Substance Use Disorder, Improves Maternal and Infant Outcomes,” Agency for Healthcare Research and Quality Patient Safety Network, March 11, 2021, https://psnet.ahrq.gov/innovation/project-nurture-engages-pregnant-people-substance-use-disorder-improves-maternal-and.
15. Oregon Health Authority and Comagine Health, “Nurture Oregon Progress,” 2023, https://www.oregon.gov/oha/HSD/AMH/DataReports/Nurture-Oregon-Progress-Report-2023.pdf. K. John McConnell et al., “Project Nurture Integrates Care and Services to Improve Outcomes for Opioid-Dependent Mothers and Their Children,” Health Affairs 39, no. 4 (2020): 595-602, https://doi.org/10.1377/hlthaff.2019.01574. “Treatment of Opioid Use Disorder Before, During, and After Pregnancy,” Centers for Disease Control and Prevention, May 1, 2026, https://www.cdc.gov/opioid-use-during-pregnancy/treatment/index.html.
16. U.S. Department of Health and Human Services, “Contingency Management for the Treatment of Substance Use Disorders: Enhancing Access, Quality, and Program Integrity for an Evidence-Based Intervention,” 2023, https://aspe.hhs.gov/reports/contingency-management-treatment-suds. Dennis J. Hand et al., “Contingency Management Interventions for Tobacco and Other Substance Use Disorders in Pregnancy,” Psychology of Addictive Behaviors 31, no. 8 (2017): 907-21, https://pmc.ncbi.nlm.nih.gov/articles/PMC5714659/.
17. Deborah J. Cohen et al., “Functions of Interdisciplinary Primary Care Teams That Support Pregnant People With Substance Use Disorders,” The Annals of Family Medicine 23, no. 5 (2025): 434-40, http://www.annfammed.org/content/23/5/434.abstract.
18. K. John McConnell et al., Project Nurture Integrates Care and Services to Improve Outcomes for Opioid-Dependent Mothers and Their Children.
19. Megan B. Cole et al., “Provision of On-Site Prenatal Care Services at U.S. Federally Qualified Health Centers,” Annals of Internal Medicine (2026): https://pmc.ncbi.nlm.nih.gov/articles/PMC13367413/.
20. Casey Anderson et al., “Lessons Learned From the Implementation of an Integrated Prenatal Opioid Use Disorder Program,” Nursing for Women’s Health 26, no. 3 (2022): 215-25, https://www.sciencedirect.com/science/article/pii/S1751485122000927.
21. Mendivil E. Murphy, “Supporting Individuals Experiencing Perinatal Opioid Use Disorder: A Guide for CHW/Rs,” University of Arizona Center for Rural Health, 2025, https://crh.arizona.edu/sites/default/files/2025-11/251106Perinatal-Opioid-Guide.pdf.
22. Amanda Fallin-Bennett, Alex Elswick, and Kristin Ashford, “Peer Support Specialists and Perinatal Opioid Use Disorder: Someone That’s Been There, Lived It, Seen It,” Addictive Behaviors 102 (2020): 106204, https://www.sciencedirect.com/science/article/pii/S0306460319309049.
23. Ruirui Huang et al., “Effectiveness of Peer Support Intervention on Perinatal Depression: A Systematic Review and Meta-Analysis,” Journal of Affective Disorders 276 (2020): 788-96, https://www.sciencedirect.com/science/article/pii/S0165032720324459.
24. William L. White and William Cloud, “Recovery Capital: A Primer for Addictions Professionals,” Counselor 9, no. 5 (2008): 22-27, https://www.naadac.org/assets/2416/whitewlcloudw2008_recovery_capital_a_primer.pdf.
25. David Eddie et al., “Peer Recovery Support Services and Recovery Coaching for Substance Use Disorder: A Systematic Review,” Current Addiction Reports 12, no. 1 (2025): 40, https://doi.org/10.1007/s40429-025-00645-8. Jessica F. Magidson et al., “Peer Recovery Coaches in General Medical Settings: Changes in Utilization, Treatment Engagement, and Opioid Use,” Journal of Substance Abuse Treatment 122 (2021): 108248, https://www.sciencedirect.com/science/article/pii/S0740547220305055.
26. Laura Sternberger et al., “Lessons Learned Serving Pregnant, Postpartum, and Parenting People With Substance Use Disorders in Massachusetts: The Moms Do Care Program,” Maternal and Child Health Journal 27, no. 1 (2023): 67-74, https://doi.org/10.1007/s10995-023-03775-5.
27. Meghan Gannon et al., “Doula Engagement and Maternal Opioid Use Disorder (OUD): Experiences of Women in OUD Recovery During the Perinatal Period,” Midwifery 106 (2022): 103243, https://www.sciencedirect.com/science/article/pii/S0266613821003181.
28. Meghan Gannon et al., “Someone Is There With You through This [Pregnancy] That Isn’t Seeing You Through a Negative Lens”: Considerations for Integrating Doula Referrals Into Opioid Treatment Programs,” Journal of Substance Use and Addiction Treatment 169 (2025): https://doi.org/10.1016/j.josat.2024.209585.
29. The National Academy for State Health Policy, “How States Promote Recovery for Pregnant and Parenting Women With Substance Use Disorder,” Oct. 30, 2018, https://nashp.org/how-states-promote-recovery-for-pregnant-and-parenting-women-with-substance-use-disorder/. Policy Center for Maternal Mental Health, “The Difference Between Doulas, CHWs and Peer Support Workers, 2024, https://policycentermmh.org/lay-professionals/. “Medicaid Postpartum Coverage Extension Tracker,” KFF, July 15, 2026, https://www.kff.org/medicaid/medicaid-postpartum-coverage-extension-tracker/.
30. “Medicaid Postpartum Coverage Extension Tracker,” KFF. Wisconsin Legislature, 2025 Wisconsin Act 102, Senate Bill 23 (2025), https://docs.legis.wisconsin.gov/2025/related/acts/102.
31. Legislative Analysis and Public Policy Association, “Substance Use During Pregnancy and Child Abuse or Neglect: Summary of State Laws,” 2024, https://legislativeanalysis.org/wp-content/uploads/2024/06/Substance-Use-During-Pregnancy-and-Child-Abuse-50-State-Summary.pdf. Stacey Mckenna and Courtney Joslin, “Prenatal Substance Use Laws Inadvertently Endanger Healthy Families: A Review of Laws Affecting Pregnant Women in Recovery and Their Children,” 2025, https://www.rstreet.org/research/prenatal-substance-use-laws-inadvertently-endanger-healthy-families-a-review-of-laws-affecting-pregnant-women-in-recovery-and-their-children/.
32. Emilie Bruzelius et al., “Prenatal Drug Use Criminalization and Health System Avoidance: Evidence From Births in Alabama, South Carolina, and Tennessee, 1989-2019,” Social Science & Medicine 387 (2025): 118716, https://www.sciencedirect.com/science/article/pii/S0277953625010470.
33. Emilie Bruzelius et al., “Punitive Legal Responses to Prenatal Drug Use in the United States: A Survey of State Policies and Systematic Review of Their Public Health Impacts,” International Journal of Drug Policy 126 (2024): 104380, https://www.sciencedirect.com/science/article/pii/S0955395924000653. “Neonatal Abstinence Syndrome (NAS),” March of Dimes, January 2025, https://www.marchofdimes.org/find-support/topics/planning-baby/neonatal-abstinence-syndrome-nas.