Why is this Toolkit Needed?

Opioid Use Disorder has ravaged many parts of the United States and is increasing rapidly in California. While the emphasis in this toolkit is on Opioid Use Disorder (OUD), most of the principles and resources described herein are applicable to all Substance Use Disorders (SUD). Pregnancy offers a unique opportunity for intervention, as pregnant women may be more willing to seek care and more motivated to remain in treatment than at other times in their lives.

Several studies now report that opioid overdose deaths decline during pregnancy, but peak in the year following pregnancy, and are now one of the leading causes of mortality among women during that period. One study estimates that OUD pregnancy-related hospitalizations cost an additional $30 million dollars annually (Whiteman VE, et al, 2014).

Significant morbidity and costs may be associated with infants exposed to opioids, particularly when pregnant mothers have not been in treatment prior to delivery. Health care data highlight the attention that newborns with Neonatal Abstinence Syndrome (NAS) need and deserve. Incidence of newborns with NAS increased 5-fold from 2000 to 2012, from 1.2 to 6 per 1000 live births, and continues to increase, with recent data citing as many as 20 cases per 1000 live births (Wachman EM, et al, 2018). In California, NAS incidence increased from a rate of 2.9 per 1,000 delivery hospitalizations in 2008 to 6.4 per 1000 in 2013, according to data from the California State Inpatient Databases. The cost of NAS admissions was almost $316 million in 2012, not including ongoing costs for follow-up care. The first several days after birth are vital for establishing a bond between mother and newborn, identifying and monitoring symptomatic newborns, and initiating appropriate management. Ensuring that newborns are discharged to a stable environment and with proper medical follow-up is essential to achieve the best possible outcomes.

There are many barriers to safe, effective, patient-centered care of pregnant and parenting women with OUD and their newborns, including:

  1. Knowledge gaps among inpatient and outpatient obstetric and pediatric providers and staff including
    1. Neurobiological underpinnings of addiction
    2. The evidence-based approach to OUD treatment
    3. Uses of screening and assessment questionnaires as well as biological (toxicology) testing
    4. Performing brief interventions
    5. Knowledge of available community resources for referrals following a positive screen
    6. Prenatal plans of care for women with OUD
    7. Inpatient care, including pain management in both the intrapartum and postpartum periods
    8. Appropriate monitoring of withdrawal symptoms in newborns
    9. Appropriate non-pharmacological and when needed, pharmacological management of affected newborns
    10. Best practices for family-centered care of opioid exposed newborns and mothers
    11. Discharge Plan of Safe Care for mothers and newborns, including treatment and recovery service continuity
  2. Gaps in care coordination and communication among:
    1. Prenatal care providers, Medication Assisted Treatment (MAT) providers, and drug treatment and recovery services
    2. Outpatient providers and inpatient providers
    3. Obstetric and pediatric providers
    4. Inpatient obstetric providers, MAT and treatment and recovery providers for post discharge care
    5. Pediatric providers and early childhood service providers
    6. Child Protective/Welfare Services and providers or staff
  3. Stigma and prejudice towards women with OUD by providers and staff
  4. Inadequate capacity to meet the treatment and recovery needs of pregnant and parenting women:
    1. Insufficient numbers of MAT waivered women’s health care providers
    2. Insufficient recovery and treatment options for pregnant and parenting women
    3. Insufficient access to MAT for pregnant and parenting women who are incarcerated
    4. Reluctance of some narcotic treatment programs and other providers to offer all three FDA-approved options for MAT

This toolkit is designed to support the preparation of maternity and pediatric caregivers to overcome barriers and deliver safe, effective, and coordinated care for mothers and newborns affected by OUD. The ultimate goal, if possible, is to keep the mother and newborn together. This can often provide the motivation necessary to do the work of treatment and recovery. Multiple studies have shown the importance of the mother-newborn bond in the well-being and development of the child. This can be facilitated by our second goal which is to keep the mother in care. Research has shown the importance of on-going care, after the initial treatment, to support the mother in her recovery. This would include on-going assessments of her biopsychosocial needs, modeling new coping skills, assisting her to navigate the health care and other systems and teaching her about child development and parenting.

We are thankful to our colleagues in other states as well as The Alliance for Innovation on Maternal Health (AIM), who have so generously shared many of their resources to aid us in the construction of this toolkit. In particular, we wish to thank Marilyn Meyer, MD, of The Northern New England Perinatal Quality Improvement Network and Patricia Lee King, Ph.D. of the Illinois Perinatal Quality Collaborative.



  • Whiteman VE, Salemi JL, Mogos MF, Cain MA, Aliyu MH, Salihu HM. Maternal opioid drug use during pregnancy and its impact on perinatal morbidity, mortality, and the costs of medical care in the United States. J Pregnancy. 2014;2014:906723. doi:10.1155/2014/906723.
  • Wachman EM, Schiff DM, Silverstein M. Neonatal abstinence syndrome: Advances in diagnosis and treatment.  JAMA. 2018 Apr 3;319(13):1362-1374. doi: 10.1001/jama.2018.2640.
  • California Child Welfare Co-Investment Partnership. 2017. “A Matter of Substance: Challenges and Responses to Parental Substance Use in Child Welfare.” Insights, Volume XIII, 16.
  • Corr TE, Hollenbeak CS. The economic burden of neonatal abstinence syndrome in the United States. Addiction.  2017;112(9):1590-1599. doi: 10.1111/add.13842.