Executive Summary

Maternal and newborn providers and staff face an increasing number of opportunities to care for women and newborns affected by Substance Use Disorder (SUD), and particularly Opioid Use Disorder (OUD), in offices, clinics, urgent care centers, and hospitals.

"As California, and the nation, has seen rising rates of social inequity, homelessness, mental illness, and despair, so too do we see increases in opioid abuse, addiction, overdose and deaths, especially among those most marginalized in our society.

The State of California, working in partnership with health care, academia, philanthropy, and at the community level, has taken a collective action approach and built a structure, anchored by the Statewide Opioid Safety Workgroup, to track the epidemic and pivot policy and programmatic interventions to address the changing realities of addiction in the state.

Because of our collective efforts, California has consistently had rates below the national average. Yet, the magnitude of the impact of the epidemic is great, and the work of the state and our partners is ongoing."

- Dr. Karen Smith, Former State Public Health Officer and CDPH Director

The project team from Health Management Associates, California Perinatal Quality Care Collaborative and California Maternal Quality Care Collaborative gathered a diverse task force of obstetric and pediatric providers, anesthesiologists, nurses, social workers, and public health professionals to create a toolkit focused on maternal and newborn care from the prenatal period through hospital discharge. Content creators and reviewers for The Mother & Baby Substance Exposure Toolkit are experts in their fields.

The toolkit takes into consideration the intricacies that potential scenarios present: difficulties in screening, stigmatized care, variability of provider and staff knowledge, and the challenges of care coordination. Also taken into consideration is the work of the many stakeholders who are committed to the well-being of both mother and newborn and who have identified opportunities for improved collaboration. This toolkit clarifies practices that support and improve the care of mother and newborn, guided by the following foundational principles:

  • Every pregnant woman should be screened for substance use
  • Every pregnant woman with OUD should be on Medication Assisted Treatment (MAT)
  • An increasing evidence base supports the use of non-pharmacologic treatment for newborns with Neonatal Abstinence Syndrome (NAS)
  • Mothers and babies should receive support to keep them together

The included implementation guide offers guidance on how to put this toolkit into practice. Each of the best practices is followed by resources drawn from experts and programs around the country. The toolkit is divided into the following sections, each listing best practices within critical topic areas:


Topic areas include: universal screening with a validated verbal screening tool, maternal urine toxicology and the role of explicit/implicit bias in decision-making, and implementing selective newborn biological toxicology testing.


Topic areas include: inpatient treatment protocols, pain management and anesthesia, minimizing opioid use, and breastfeeding, pharmacologic and nonpharmacologic treatment of newborns with NAS, and establishing a pharmacologic weaning protocol

Transitions of Care

Topic areas include: creating a dyad-centered Plan of Safe Care, implementing a discharge checklist, linking to home visitation programs and other resources, and communication with the follow-up newborn provider.


Topic areas include: educating staff about OUD, NAS, stigma, and Trauma-Informed Care

It is important to state here that there are many people in the community who do not identify as women but who desire to have a child or are currently pregnant or in the postpartum period. While we use the term mother in this toolkit, we must reiterate that all birthing people are equally deserving of patient-centered care that helps them attain their full potential and live authentic, healthy lives. For this endeavor to be successful, providers and community collaborators must work toward more inclusivity and best practices that are free of judgement and predetermined norms.

The term NAS will be used in this toolkit to refer to newborns who are withdrawing from substances to which they were exposed in utero, with a focus primarily on withdrawal from opioids.  In the past few years, the term NOWS (neonatal opioid withdrawal syndrome) has been introduced to describe the subset of NAS which relates to opioid withdrawal.  To avoid confusion, and until NOWS comes into more widespread use with both the medical community and the public, this toolkit will continue to use the term NAS.

The overarching goals of this toolkit are to maintain the mother/baby dyad whenever possible, and to keep the patient in treatment, thereby reducing the incidence of NAS. These goals drive a lucidity of purpose to offer safe, effective, patient-centered, hopeful care that is free of stigma and prejudice. As they carefully mapped out the best available, evidence-based care practices in this toolkit, the experts were guided by the lessons learned from the personal stories of patients, many with histories of abuse and no place left to turn. Clearly, shared decision making is a key part of these best practices. The toolkit authors acknowledge that more work lies ahead. Community collaboration must be expanded, more data need to be gathered, and patient voices must be amplified. The authors and collaborating partners on this project are grateful for the work of others who began this journey before us, and we look forward to further collaboration on behalf of all community members, newborns, and families affected by opioid use disorder.

Lastly, readers should remember that this toolkit is considered a resource, but does not define the standard of care in California. Readers are advised to adapt the guidelines and resources based on their local facility’s level of care and patient populations served and are also advised to not rely solely on the guidelines presented here.