Part 1: Breaking the Silence—Understanding Substance Use in Pregnancy
Series: More Than One Life: Navigating Substance Use Disorder in Pregnancy
Introduction: A Hidden Reality
Maria sat in the crowded clinic waiting room, eyes fixed on the floor, her fingers nervously twisting a pamphlet about prenatal care. Pregnant for the first time at 24, her thoughts raced—excitement mingled with fear. But another emotion weighed heaviest: shame.
Maria had been using prescription opioids to manage chronic pain from an old car accident, medications prescribed years ago without a clear exit plan. When she discovered she was pregnant, joy quickly turned to dread. “Will my baby be okay? Can I even tell my doctor?” The questions circled endlessly.
When her name was finally called, she stood, heart pounding, unsure if honesty would lead to support or punishment. She had heard stories—mothers reported to authorities, babies taken away at birth. All she wanted was a healthy child and to feel supported in getting there. But fear kept her silent.
Maria is not alone. Thousands of pregnant individuals face similar anxieties every year, battling not just substance use, but stigma, misinformation, and fear of criminalization.
This article is the first in a multi-part series on substance use disorder (SUD) in pregnancy. In the next few issues, we’ll explore clinical management strategies, innovative care models, legal and ethical considerations, and the crucial postpartum period. Each installment will offer both medical insight and lived experience, centering the voices of those most affected. Our goal is to replace fear with fact—and isolation with community. The result? Silence. Missed care opportunities. Unnecessary suffering for both parent and child.
Why This Conversation Matters
In a world that often turns a blind eye to the complexities of substance use during pregnancy, the silence is deafening. Our society, rife with judgments and predetermined narratives, too often strips away the humanity of those who navigate this harrowing path.
Understanding substance use disorder (SUD) in pregnancy requires more than clinical precision. It demands empathy, context, and a willingness to challenge deeply embedded biases—especially those that disproportionately harm Black and Brown women. Every patient navigating this experience holds more than one life in their hands—and deserves more than judgment in return.
The Big Picture: How Common Is Substance Use in Pregnancy?
Substance use during pregnancy is more common than many realize. In the U.S., approximately 1 in 12 pregnant individuals report using substances such as opioids, cannabis, alcohol, or stimulants. The past decade has seen:
Opioids: A dramatic rise linked to the opioid epidemic, with approximately 8.2 per 1,000 births impacted.
Cannabis: Increasingly common as legalization spreads, despite limited clarity around prenatal safety.
Alcohol: Persistent use despite widespread awareness of fetal alcohol spectrum disorders.
Stimulants (e.g., cocaine, methamphetamine): Still prevalent, particularly in underserved communities.
Dispelling Common Myths
Let’s quickly dispel some prevalent myths:
🛑 Myth: Cannabis is harmless during pregnancy.
Reality: Cannabis use during pregnancy may lead to low birth weight and developmental issues.
🛑 Myth: Medication-assisted treatment (MAT) harms babies.
Reality: MAT, including medications like buprenorphine and methadone, is the safest and most effective way to manage opioid use during pregnancy.
🛑 Myth: If someone is still using substances, they don’t care about their baby.
Reality: Many pregnant individuals deeply care about their baby and want help, but are terrified of punishment, losing custody, or being judged. Stigma drives silence—and silence blocks care.
🛑 Myth: You can tell if someone is using substances just by looking at them.
Reality: Substance use doesn’t have a look. It crosses race, class, age, and profession. Assumptions based on appearance often lead to missed diagnoses or harmful bias in care.
These myths persist because we’ve replaced evidence with judgment. Dispelling them is the first step in creating a healthcare system that centers on truth, not stigma.
How Substance Use Affects Mom and Baby
Substances impact both the pregnant individual and their baby in complex ways:
Opioids: Risk of neonatal withdrawal syndrome, preterm birth.
Alcohol: Risk of fetal alcohol spectrum disorders, cognitive and developmental delays.
Cannabis: Potential cognitive and developmental impairments, although research is ongoing.
Stimulants: Increased risk of preterm delivery, low birth weight, placental abruption.
But what the science shows is only part of the story. The emotional and psychological weight of navigating pregnancy while managing substance use is just as significant—and often overlooked in traditional care.
Screening, Diagnosis, and Compassionate Care
Identifying substance use early through compassionate screening is crucial. Validated tools like T-ACE, 4P’s Plus, and CRAFFT help clinicians provide early, supportive interventions without stigma.
A substance use disorder diagnosis follows DSM-5-TR criteria, based on patterns and severity of use. Early diagnosis enables timely, supportive interventions and healthier outcomes for parent and child alike.
💡 Patient Story Spotlight
Anna’s voice trembled as she spoke with her doctor. After months of fear, she finally disclosed her substance use. Expecting judgment, Anna instead received understanding, clear guidance, and support. With a comprehensive care plan, Anna was empowered to manage her pregnancy safely and confidently. Her experience underscores the transformative power of compassionate care.
The Power of Compassionate Care
Substance use disorder isn’t a moral failing. It’s a medical condition—and one that can be treated. Screening tools like T-ACE, 4P’s Plus, and CRAFFT are designed to open doors to early, supportive care. But how they are used makes all the difference.
For many patients, “routine screening” feels like surveillance. The line between medical care and policing can blur quickly, especially in a system shaped by racial bias and punitive laws.
I’ll never forget one of my first patients—a young woman of color, pregnant and battling heroin addiction. She arrived at each visit cloaked in fear, expecting judgment. But what she needed was trust. And when she finally found it, her path changed.
Her story—and others like it—taught me that treatment starts with humanity. It’s not enough to ask the right questions. We have to listen without suspicion, educate without condescension, and support without conditions.
Centering Dignity, Not Discipline
Too often, current medical practices prioritize compliance over compassion. We must shift from punishment to partnership—from asking “What’s wrong with you?” to “What happened to you?”
Confidentiality, especially for adolescents and marginalized patients, is not just a guideline—it’s a lifeline. Care should never cost someone their baby, their rights, or their safety.
Stories of Hope
Anna’s voice trembled as she finally told her provider about her substance use. She braced for the worst—but what she received was guidance, reassurance, and respect. She built a care plan and walked into motherhood empowered.
Another woman—once struggling with opioid use—now leads peer support circles, helping others walk the same path. Their stories are reminders: recovery is possible. Safe, compassionate care makes the difference.
Pathways to Change
Normalize Screening—But With Care
Implement screening across all patients, but center it on education, not suspicion. Use trauma-informed approaches.Educate Both Sides
Equip providers with anti-bias training and clear, evidence-based guidelines. Give patients tools to ask questions and seek support early.Confront Systemic Injustice
Push back against laws that criminalize pregnancy with SUD. Advocate for treatment access, protect confidentiality, and fund community-based programs.Create Safe, Shame-Free Spaces
Build care models rooted in respect and consent. Establish therapeutic alliances, especially with communities historically mistreated by healthcare.Uplift Recovery Stories
Representation matters. Share stories of hope, resilience, and healing to counter fear-based narratives and inspire change.
Practical Resources
Call to Engagement
We invite you to subscribe for upcoming issues, share your experiences, and join our community committed to informed, compassionate care. Together, we can shift the narrative from silence to support—and ensure that every pregnant person navigating SUD is seen, heard, and helped.
A Final Word
Every interaction with a patient navigating substance use during pregnancy is a chance to build trust—or to break it. It's a balance of compassion and science, listening and guiding, confronting bias and fostering understanding.
By breaking the silence, we create a future where pregnant individuals with SUD are seen fully, supported holistically, and treated with dignity—not discipline.
As we move through this series, we will dive deeper into what compassionate, evidence-based care looks like in real-world settings. From treatment plans and perinatal protocols to postpartum follow-up, policy reform, and patient storytelling, future installments will offer practical guidance for both providers and families. We’ll also highlight innovative programs and advocacy efforts across the country, helping us all imagine—and build—a more just and healing future. Let us rise to meet that future—with knowledge in our hands and empathy in our hearts.