States Strategies to Support Pregnant and Parenting People with Substance Use Disorder

Pregnant and parenting people with substance use disorder (SUD) encounter numerous barriers to accessing evidence-based treatment and recovery services, including stigma, transportation challenges, and fear of interaction with child protective and legal systems. As a result, most pregnant people with SUD do not receive treatment and are, consequently, at increased risk of experiencing poor birth outcomes. Similarly, pregnant people with untreated SUD are more likely to deliver infants prematurely and at low birth weight. Pregnant and parenting people with SUD are also at increased risk for pregnancy-related death; data published by the Centers for Disease Control and Prevention indicate that mental health conditions (including SUDs) contribute to nearly a quarter of pregnancy-related deaths, and a Journal of the American Medical Association (JAMA) study found that “among pregnant and postpartum persons, drug overdose mortality increased approximately 81% between 2017 and 2020.”  

 This article provides an overview of strategies states can use to ensure access to needed SUD treatment in the prenatal and postpartum periods, including: (1) extending postpartum Medicaid coverage, (2) allocating opioid settlement funds to support pregnant and parenting people with SUD and their families, and (3) implementing policies that decriminalize substance use during pregnancy.  

 Expansion of Medicaid Postpartum Coverage 

 While Medicaid pays for nearly half of all births across the country, before the passage of ARPA, roughly 50% of birthing people enrolled in Medicaid lost coverage 60 days after giving birth. In practice, this meant that many postpartum individuals lost access to vital SUD treatment services. One recent study found that of pregnant women entering treatment, 52.5% were Medicaid recipients, while 32.7% were uninsured.  

 Since the passage of ARPA, most states have extended postpartum coverage up to 12 months, either through a State Plan Amendment (SPA) or a Medicaid 1115 Demonstration Waiver. Earlier this month, Missouri became the 40th state to do so. ARPA granted states the flexibility to use a SPA to extend continuous Medicaid coverage up to 12 months postpartum, rather than through the more traditional Medicaid Waiver. States pursuing the SPA option under ARPA must provide comprehensive Medicaid benefits to qualifying individuals, and the original five year SPA duration limit has since been made indefinite by the Consolidated Appropriations Act of 2023.    

 Extending continuous postpartum Medicaid coverage supports pregnant and parenting people with SUD by preventing coverage churn and ensuring continued access to evidence-based treatment and recovery services. Individuals who retain continuous Medicaid coverage postpartum have been shown to use three-fold the amount of mental health and SUD services. Extending postpartum coverage for this population also saves lives. States that have adopted the Affordable Care Act Medicaid Expansion have experienced a significantly smaller increase in maternal mortality as compared to non-expansion states, and maintaining insurance coverage for a longer period postpartum for individuals that rely on that coverage opportunity may be associated with an even greater reduction in maternal deaths.
 

Using Opioid Settlement Dollars to Support Pregnant and Parenting People with SUD 

Since initial opioid settlement agreements were announced in July 2021, participating states have taken great effort to develop the infrastructure and spending methodologies necessary to responsibly allocate settlement funds. The 46 participating states must distribute their respective portions of the $26 billion settlement over the course of 18 years, and 70% of awarded funds must be put toward “opioid remediation efforts.” Exhibit E of the settlement agreement lists a series of approved opioid remediation strategies for states to consider, including strategies to address the needs of pregnant or parenting people and their families, and babies with neonatal abstinence syndrome (NAS). Several states are prioritizing these populations in their strategic plans to allocate settlement funds and are using the following specific strategies to do so:  

1. Providing training and education and increase provider capacity for providers working with pregnant and parenting people with SUD. 
2. Investing in Peer Navigators/Supports and Community Health Workers for pregnant and parenting people. 
3. Improving NAS data collection, analysis, and infrastructure. 
4. Increasing engagement and retention in evidence-based treatment for opioid use disorder (OUD) for pregnant and parenting people and those who could become pregnant. 
5. Enhancing family support and home-based wrap-around services for families affected by SUD. 
6. Expanding the continuum of care for infants born with NAS, including education, prevention, screening, and long-term care. 

Allocating opioid settlement funds towards addressing NAS and supporting pregnant individuals with SUD presents a valuable opportunity to build upon the existing evidence-based programs being implemented across the country. In Washington State, for example, evidence-based lactation guidance and best practices have been developed for mothers with SUD or those who are currently prescribed Medication for Opioid Use Disorder (MOUD). This guidance has been made available in documents tailored to both patients and providers. Several states, including Oregon and Texas, have established pilot programs to increase access to and awareness of medication-assisted treatment (MAT) services for pregnant individuals, and legislation was passed in New York, Vermont, and Washington to increase provider training on treating SUD during pregnancy.  

State Efforts to Decriminalize Treatment 

Several states have also made efforts to decriminalize potential pathways to treatment and combat stigma associated with receiving treatment for SUD during pregnancy. Pregnant and parenting people with SUD and families receiving treatment services for NAS face stigma through erroneous language, misinformation, disproportionally punitive measures, racism, and the undermining of their parent-child relationships. Punitive policies that require providers to report drug use during pregnancy to child protective services discourage pregnant people from entering treatment, whereas policies that empower providers to engage pregnant people in SUD treatment result in better outcomes for expecting parents. treatment. The Substance Abuse and Mental Health Services Administration (SAMSHA) and the National Institute on Drug Abuse (NIDA) have both released provider guidance addressing how to reduce stigma as a barrier to treatment, and many states have followed suit in recent years.