Barriers to opioid replacement therapy in pregnant women with opioid use disorder: a systematic review

Abstract

Background

Opioid use disorder (OUD) during pregnancy has increased dramatically, paralleling epidemic trends in the general population. Pregnant women with OUD face considerable risks of adverse outcomes. While medications for opioid use disorder (MOUD) is the mainstay of treatment, substantial barriers limit its implementation. Despite the critical need for effective interventions, a comprehensive synthesis of the challenges to MOUD during pregnancy remains lacking. This review examines these barriers to improve treatment access and outcomes for this vulnerable population.

Methods

This review was conducted in accordance with the PRISMA 2020 guidelines and was registered in PROSPERO (registration number: CRD420251047657). We searched for peer-reviewed articles in PubMed, Scopus, and ScienceDirect published between 2015 and 2025, using a combination of keywords and MeSH terms. Two independent reviewers screened studies, extracted data, and assessed quality using the Joanna Briggs Institute (JBI) critical appraisal tools. Discrepancies were resolved through consensus with a third author. Data were synthesized narratively to identify key challenges in the treatment of OUD during pregnancy.

Results

Of the 9,288 articles identified from databases and websites, 23 met the eligibility criteria, including 14 qualitative studies, 5 cross-sectional studies, and 4 review articles. Patient-related barriers to accessing MOUD for pregnant women with OUD included fear of stigma and child custody loss, concerns about fetal risks, childcare and legal issues, coping with abuse, guilt, social pressure, and financial constraints. Meanwhile, provider-related barriers involved knowledge gaps, inadequate training, bias, stigma, time constraints, and the perceived complexity of treating OUD during pregnancy. Moreover, system-level barriers such as fragmented care models, geographic disparities, gaps in insurance coverage, and punitive policies further limited access to treatment.

Conclusion

Pregnant women with OUD face barriers including stigma, childcare demands, provider bias, training gaps, fragmented care, financial and insurance issues, and punitive policies. Implementing patient-centered care, provider education, policy reforms, and practical supports may help promote compassionate, equitable treatment for this vulnerable population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13011-025-00675-5.

Introduction

The use of illicit drug for pleasurable effects dates back thousands of years [1, 2]. The most common reasons for opioid use include pain relief, managing anxiety, depression, and insomnia, as well as mood enhancement. However, excessive opioid use, also known as ‘opioid use disorder’ (OUD), is a pressing global public health problem, contributing to significant preventable morbidity and mortality [3]. OUD is defined as the repeated occurrence over a 1-year time period of 2 or more specific criteria related to chronic opioid use [4]. These criteria include sacrificing important life activities to use opioids, spending excessive time obtaining or using them, and experiencing withdrawal symptoms upon abrupt cessation [4]. An estimated 26.8 million people are living with OUD globally, with > 100,000 opioid overdose deaths annually [5]. Illicit drug use has contributed to 0.9% of disability-adjusted life years [3]. Opioid use, even in non-fatal doses, is associated with serious co-morbidities [6]. Furthermore, the global burden of communicable diseases such as hepatitis B, hepatitis C, and HIV is exacerbated by IV illicit drug abuse [7].

Rates of opioid use in pregnancy have paralleled the rapid increases observed in the general population [8]. Approximately 20% of women fill opioid prescriptions during pregnancy [9]. About 5% of North American women use illicit drugs during pregnancy [10], and the proportion is increased by more than fourfold during 1999–2014 [11]. Women with OUD face significantly higher risks of adverse pregnancy outcomes compared to non-opioid users. They face higher risks of death, cardiac arrest, and adverse outcomes such as intrauterine growth restriction, placental abruption, preterm birth, low birth weight, microcephaly, postpartum hemorrhage, stillbirth, neonatal opioid withdrawal syndrome, and preeclampsia [12–16]. Contributing factors for this increased risk include chronic viral infections, poor health and psychosocial conditions, and inadequate prenatal care [17].

OUD complicates pregnancy through significant psychosocial and medical comorbidities, necessitating universal screening and early treatment referral, ideally at the first prenatal encounter [18]. Medication for opioid use disorder (MOUD) is a critical component of comprehensive care for pregnant individuals with OUD, as it has been shown to reduce opioid use, overdose, and improve both maternal and neonatal outcomes. MOUD includes methadone, buprenorphine, naltrexone, and other medications used for withdrawal management; however, the latter are not considered primary forms of MOUD. Methadone and buprenorphine are the most commonly utilized opioid replacement therapies (ORT). Naltrexone, an opioid antagonist, is less frequently prescribed due to the requirement for complete detoxification and a sustained opioid-free interval prior to initiation. Continued engagement in MOUD during the postpartum period is also essential to prevent relapse and support long-term pregnancy outcomes [19–21].

MOUD, particularly long-acting opioids combined with psychosocial support, is an evidence-based approach for managing OUD in pregnant individuals. In the absence of MOUD, relapse rates and the risk of adverse maternal and neonatal outcomes increase significantly [21, 22]. MOUD stabilizes opioid levels, reduces cravings, and is associated with improved maternal and neonatal outcomes compared to untreated opioid use or withdrawal [23, 24]. Methadone is the standard treatment for OUD during pregnancy [23, 25], but recent studies found that both methadone and buprenorphine improve neonatal and maternal outcomes. Although methadone remains the standard of care, there is an increasing tendency to move towards buprenorphine as a first-line treatment, because of both its availability and evidence of improved outcomes compared to methadone [21].

Despite robust evidence supporting its efficacy and well-documented benefits, MOUD particularly ORT, remains underutilized among pregnant individuals with OUD [22, 26, 27]. This underuse is further compounded by numerous barriers to care [28]. Barriers to care arise from systemic issues, provider bias, and the unique needs of pregnant women. Limited access in rural areas, where only few addiction specialists practice, combined with a fragmented healthcare system, makes it difficult for many to seek treatment. Healthcare system challenges like lack of childcare, transportation barriers, and inflexible scheduling often hinder treatment access [29, 30]. Clinicians often exhibit stigma towards pregnant women with OUD, leading to reluctance in prescribing ORT [31]. Obstetricians frequently defer OUD management to specialists, resulting in fewer than 20% of pregnant women receiving appropriate treatment [32].

Pregnant women with OUD face many responsibilities, and without support services, maintaining consistent treatment is challenging. Fears of losing custody may also discourage them from seeking care [30]. Many women are also misinformed about the safety and benefits of ORT during pregnancy. This lack of awareness, combined with fears of neonatal abstinence syndrome, can make them reluctant to seek treatment [33]. Although these barriers are substantial, growing awareness of OUD as a treatable condition during pregnancy may help improve support systems and expand treatment options. While understanding these barriers is essential to improving treatment access and outcomes, comprehensive evidence on the obstacles to MOUD for pregnant women with OUD remains limited. This review aims to synthesize the best available evidence on the barriers to MOUD during pregnancy.

Methods

This review was conducted according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) 2020 statement [34]. The complete methods section is documented in the PROSPERO international prospective register of systematic reviews and available at: https://www.crd.york.ac.uk/PROSPERO/view/CRD420251047657.

Search Strategy

We conducted a comprehensive search of electronic databases including PubMed, Scopus, and ScienceDirect as well as websites such as Google Scholar, covering the period from April 1 to June 7, 2025. Our search strategy included keywords like opioid use disorder, pregnant women, medications for opioid use disorder (MOUD), and opioid replacement therapy, along with Medical Subject Headings (MeSH) terms such as opioid substitution therapy, opioid agonist therapy, opiate substitution treatment, opioid-related disorder, opiate addiction, opioid-related barriers, pregnancy, and women.

Keywords and MeSH terms were combined using Boolean operators such as AND, OR, and NOT. Search phrases included combinations like ‘Opioid Use Disorder’ OR ‘Opioid-Related Disorders’ AND ‘Pregnant Women’ OR ‘Pregnant Woman’ AND ‘Medications for Opioid Use Disorder’ OR ‘MOUD’ OR ‘Opioid Replacement Therapy’ OR ‘Opioid Substitution Treatment’ OR ‘Opioid Agonist Therapy’ AND ‘Barriers’ OR ‘Opioid-Related Barriers’ to identify articles from databases and websites (Supplementary File 1). The search was limited to published, indexed articles involving human subjects and available in English. EndNote reference manager was used to remove duplicate records from multiple sources.

Eligibility Criteria

This systematic review included studies on pregnant women diagnosed with OUD, as well as those involved in their treatment, including healthcare providers and systems. Both qualitative and quantitative peer-reviewed studies published in English between 2015 and May 2025 were included. The review focused on barriers to OUD treatment during pregnancy, analyzing challenges from patient, provider, and system-level perspectives.

Screening and Study Selection

All identified articles were exported to EndNote, where duplicates were removed. Two independent authors (the first and second) conducted the initial screening by reviewing titles and abstracts against the inclusion criteria. Full-text reviews of potentially eligible articles were then conducted by the first, second, and fifth authors. To ensure methodological rigor, all steps followed a dual-review process: one author completed each step, and a second verified the work to minimize bias and errors. Disagreements were resolved by consensus or, if necessary, through review by a third author.

Data Extraction and Synthesis

Three authors independently extracted data using a standardized approach. When discrepancies occurred, other team members reviewed the articles to reach consensus. Extracted data included first author, publication year, country of study, sample size, and identified barriers, all reported in tables. For synthesis, we employed a narrative approach to analyze and interpret the findings.

Quality Assessment of Studies

We assessed the quality of included articles using the Joanna Briggs Institute (JBI) critical appraisal tools for qualitative studies, systematic reviews, and cross-sectional studies to evaluate methodological rigor in conducting narrative synthesis within systematic reviews [35–37]. Two independent authors conducted initial quality appraisals of each article, which were then verified against full texts by another third author. Any discrepancies during the appraisal process were resolved through full-team review and consensus discussion. Following a thorough critical appraisal, only articles of good quality were included (Supplementary File 2).

Results

A total of 9,288 articles were identified from databases and websites. After removing 5,887 duplicate articles using the EndNote citation manager, the remaining articles were screened using automated tools and additional exclusion criteria. As a result, 281 articles were selected for screening based on the eligibility criteria. Of these, 228 were excluded, leaving 53 full-text articles for further evaluation. Following a full-text review, 27 more articles were excluded. With the addition of 4 articles identified through Google Scholar, a total of 23 articles were eligible for inclusion in the review (Fig. 1).

Fig. 1.

Article screening flow diagram

Characteristics of Included Studies

Key characteristics of the included studies, such as the first author, title, year of publication, country, sample size, and identified barriers, were extracted. Among the 23 studies analyzed, the majority [14] were qualitative, while 5 were cross-sectional and 4 were review articles. The majority of studies included in the review were conducted in the United States, with only a single study originating from a country outside the U.S (Table 1).

Table 1.

Characteristics of included studies

Author, Year and Country	Title of article	Study design	Sample size	Identified barriers
Hannah B Apsley et al., 2024, USA	Pregnancy- and parenting-related barriers to receiving medication for opioid use disorder: A multi-paneled qualitative study of women in treatment, women who terminated treatment, and the professionals who serve them	Qualitative study	42	✓ Insufficient access to childcare to navigate appointments and meetings ✓ Fear of losing custody of, or access to their children ✓ Prioritizing their children’s needs before their own ✓ Hesitancy of physicians to prescribe medication for OUD for pregnant patients ✓ Limited access to resources in rural areas, and ✓ Difficulty navigating a complex, decentralized health system
Penelope K. Morrison, 2022, USA	Barriers to Care for Pregnant and PostPartum Women Experiencing CoOccurring Intimate Partner Violence and Opioid Use Disorder	Qualitative study	49	➢ Barriers to helpseeking/engaging in treatment: ✓ Unwillingness to disclose due to fear of stigma and being judged ➢ Barriers to help seeking for IPV – Substance Use Related: ✓ Dependency on their partner and fear of losing them ➢ Barriers to OUD Recovery – IPV Related: ✓ Being in an abusive relationship and using substances as a coping mechanism ✓ Abusive partners: partners who are upset because the individual is on maintenance medication, due to misunderstanding or disagreement, and concerns that it may increase risk to the fetus. ➢ Barriers to OUD Recovery – Pregnancy/PostPartum Related: ✓ A woman’s body changes while they’re pregnant and risk of relapse ➢ Barriers to caring/treating IPV/OUD: ✓ Lack of screening for IPV or OUD across service contexts ✓ Provider’s discomfort with IPV or OUD due to lack of experience, knowledge, or expertise in IPV or OUD ✓ Provider bias ➢ Barriers to CoLocated/Coordinated Care: ✓ Shelter/Treatment Facility Requirements ➢ Barriers to Funding: ✓ Barriers to Working Across Agencies
Stephen W. Patrick et al., 2018, USA	Barriers to Accessing Treatment for Pregnant Women with Opioid Use Disorder in Appalachian States	Cross-sectional survey study	113	✓ OAT providers were reluctant to treat pregnant women with OUD ✓ Pregnant women with Medicaid and private insurance were accepted at lower rates ✓ Longer waiting times
Chandni Joshi et al., 2021, USA, Nepal	Women-centered drug treatment models for pregnant women with opioid use disorder: A scoping review	Scoping review	26 articles	✓ Stigmatization ✓ Criminalization of substance use during pregnancy
Davida M. Schiff et al., 2022, USA	You have to take this medication, but then you get punished for taking it:” Lack of agency, choice, and fear of medications to treat opioid use disorder across the perinatal period	Qualitative study	26	✓ Participants experienced a lack of agency and autonomy surrounding medication decisions because of their pregnancy or parenting status, hindering their treatment adherence. ✓ Participants were hesitant to use medications because they wanted to minimize perceived harms to their newborn from experiencing withdrawal symptoms at birth. ✓ Participants were concerned about increased scrutiny and potential loss of custody due to mandated child protective services reporting for opioid-exposure at delivery. ✓ Participants reported that treatment environments, particularly methadone clinics, did not provide gender-responsive care, with standard inflexible visit regulations particularly difficult in the early postpartum period.
Cara Angelotta et al., 2016, USA	A Moral or Medical Problem? The Relationship between Legal Penalties and Treatment Practices for Opioid Use Disorders in Pregnant Women	Cross-sectional study	8,292	✓ Criminal justice referral, other community referral, Medicaid coverage, care provider referral, unknown referral, other health care provider referral, and ✓ Presence of state law that permits child abuse charges
Catherine Leiner et al., 2021, USA	“The elephant in the room;” a qualitative study of perinatal fears in opioid use disorder treatment in Southern Appalachia	Qualitative study	27	✓ Hesitancy to disclose the use of substances during pregnancy ✓ Fears of social services involvement ✓ Preparation for delivery ✓ Providers addressing fears
Ashley C. Lensch et al., 2022, USA	Pregnant Patients Using Opioids: Treatment Access Barriers in the Age of COVID-19	Cross-sectional survey study	128	✓ Decreased acceptance rate of pregnant women with OUD for treatment during COVID-19 ✓ No clinics provided childcare or transportation ✓ Prolonged waiting time to take treatment referrals ✓ Rare provision of employment assistance or women-only group services ✓ Forms of payment: private insurance and Medicaid
Joshua St. Louis et al., 2021, USA	Barriers to care for perinatal patients with opioid use disorder: family physician perspectives	Qualitative study	17	✓ Stigma ✓ Feeling of provider bias ✓ Social determinants of health (SDOH): the conditions in which patients live and work, such as: poverty, housing instability, and incarceration ✓ Logistical barriers: lack of transportation, distances to appointments, unreliable phone access, and lack of childcare. ✓ Cost of care and inability to pay ✓ Stigma of caring stigmatized population ✓ Time and practice burden ✓ Lack of qualified clinicians ✓ Prior authorization ✓ Lack of behavioral health services ✓ Fragmentation /lack of care coordination ✓ Lack of adequate safety net and social services ✓ Payment structures (insurance coverage /payers)
Miriam Boeri et al., 2021, USA	Barriers and Motivators to Opioid Treatment Among Suburban Women Who Are Pregnant and Mothers in Caregiver Roles	Qualitative study	58	➢ Stigma by healthcare providers ➢ MAT Perception: ✓ Participants were hesitant to believe that MAT would be beneficial, fearing that disclosing her use to physician and husband, could result in CPS intervention and a divorce. ✓ Feared exchanging one drug with another, to wean off opioids ✓ Pharmacological Effects of MAT fearing adverse pharmacological effects of using MAT ➢ MAT Clinic Operating Hours; rigid schedules: clinics open early morning and closed mid-afternoon. ➢ Treatment Facilities and Programs Barriers: ✓ Poor Access for females; treatment disparities for pregnant women ➢ Cost; variable Medicaid coverage ➢ Location; opioid treatment and harm reduction resources were mostly located in the city ➢ Relationships Acting as Barriers: ✓ Romantic Partners: Having a partner who uses or provides opioids can prevent women from seeking treatment. ✓ Family and Friends: Hardships with the family or difficulties with friends and Poor Attitudes of friends who use opioids ➢ Pregnancy: fear of medication side effect to fetus ➢ Child Protective Services: fear of losing child custody
Doris Titus-Glover et al., 2021, USA	Opioid use disorder in pregnancy: leveraging provider perceptions to inform comprehensive treatment	Qualitative study	12	➢ Lack of provider knowledge, inadequate training, and inconsistent treatment guidelines ➢ Lack of follow-up and inadequate coordination ➢ Lack of external supports and patient resources ➢ Stigma, shame, and guilt
Alice Fiddian-Green et al., 2022, USA	Women-Reported Barriers and Facilitators of Continued Engagement with Medications for Opioid Use Disorder	Qualitative study	20	➢ Interpersonal and Community-Based Social Stigma: ✓ Family and social networks ✓ Workplace settings ✓ Social media ✓ Hierarchies within the treatment and recovery community ➢ Fear, perceptions, and experiences with MOUD Pharmacotherapies: Fear of side effects and medication synergies ➢ Internalized MOUD-Related Stigma ➢ Expectations of treatment duration ➢ Opioid-specific provider mistrust
Jennifer L. Syvertsen et al., 2021, USA	Conceptualizing stigma in contexts of pregnancy and opioid misuse: A qualitative study with women and healthcare providers in Ohio	Qualitative study	46	➢ Structural stigma: ✓ Encoded barriers to care in insurance practices and punitive drug treatment ➢ Enacted stigma: ✓ Manifested as mistreatment and judgment from providers. ✓ Unpredictability of an infant diagnosis of neonatal abstinence syndrome (NAS), even when women were “doing everything right” by using MAT ✓ Anticipated stigma from fear of loss of custody ➢ Internalized stigma among women who felt guilty about the diagnosis.
Adeoluwayimika Odusi et al., 2024, Grenada	Intersectional Disparities in Opioid Use Disorder Treatment: Exploring Barriers Faced by Pregnant African-American Women	Comprehensive review article	9 articles	➢ Race: Black and Hispanic women less likely to receive Medication-Assisted Treatment (MAT) ➢ Stigma ➢ Insurance and cost
Freya Tsuda-McCaie MA et al., 2022, USA	A qualitative meta-synthesis of pregnant women’s experiences of accessing and receiving treatment for opioid use disorder	Comprehensive review /qualitative meta-synthesis	9 articles	➢ Psychological and relational barriers to engaging in treatment, including: ✓ Anxieties about the baby’s health ✓ Fears of authorities’ involvement ✓ Stigma ✓ Relationships with treatment providers
Bedrick BS et al., 2020, USA	Barriers to accessing opioid agonist therapy in Pregnancy	Cross-sectional study	1461	✓ Limited acceptance of new patients ✓ Geographic disparities of clinics concentrated in urban settings ✓ Long waiting times for appointments ✓ Incorrect provider information
Kim, Jane et al., 2022, USA	Health Care Experiences During Pregnancy and Parenting with an Opioid Use Disorder	Qualitative study	24	➢ Disrespectful care, ➢ Fear of accessing services ➢ Inconsistencies in care received ➢ Limited health and social services
Constance Guille et al., 2022, USA	Listening to women and pregnant and postpartum people: Qualitative research to inform opioid use disorder treatment for pregnant and postpartum people	Qualitative study	49	✓ Time constraints ✓ Complex needs of patients ✓ Problems with screening
Rebecca Stone, 2015, USA	Pregnant women and substance use: fear, stigma, and barriers to care	Qualitative study	30	➢ Fear of detection: ✓ Avoiding medical care ✓ Social isolation and denial of pregnancy ➢ Inadequate information about opioid replacement therapy: ✓ Concerned about never being able to stop taking methadone. ➢ Fear of Medicaid or other funds get cut off for their methadone ➢ Fear of child protective service (CPS) involvement
Carolyn Sufrin et al., 2024, USA	“They talked to me like I was dirt under their feet:” Treatment and withdrawal experiences of incarcerated pregnant people with opioid use disorder in four U.S. states	Qualitative study	32	➢ Concern for their babies ➢ Lack of counseling or accurate information about MOUD in pregnancy; ➢ Absent, delayed, or coercive care in jail; ➢ Experiences of stigma and discrimination from staff and caregivers; ➢ Structural barriers to safe transitions and continuing MOUD; and ➢ The destructive presence of child protective services for care continuity
Jamie Morton et al., 2023, USA	Stigma Experienced by Perinatal Women with Opioid Dependency in the United States: A Qualitative Meta-Synthesis	A qualitative Meta-Synthesis	12 articles	✓ stigma
Isabella Natale et al., 2023, Australia	“It can save your life, that’s all I know,” barriers and facilitators for engagement in take-home naloxone for people receiving opioid substitution treatment in regional Australia: An explorative study	Qualitative study	11	✓ Limited knowledge and understanding, ✓ Lack of information, and not personally experiencing an overdose
Banks et al., 2022, USA	Attitudes Toward Medication for Opioid Use Disorder Among Pregnant and Postpartum Women and People Seeking Treatment	Cross-sectional study	33	✓ Uncertainty regarding the appropriate dosage of MOUD and its impact on the fetus and/or neonate

Themes Identified through Narrative Synthesis

Although MOUD is the mainstay of treatment for OUD, a significant portion of pregnant women do not receive it due to barriers related to patients, healthcare providers, and the healthcare system. Several studies highlight these barriers as major obstacles to providing MOUD to pregnant women with OUD (Table 1).

Patient-Related Barriers to Medications for Opioid Use Disorder

Pregnant women with OUD face numerous self-related barriers that hinder initiation and continuation of MOUD. Fear of stigma and judgment leads many to hide their substance use due to concerns about being seen as unfit mothers. Concerns about medication and its risks to the fetus, neonatal withdrawal syndrome, and beliefs that therapy simply replaces one drug with another also deter treatment. Additionally, fear of involvement with child protective services discourages many from seeking help due to worries about custody loss or legal consequences.

Women in abusive relationships may avoid therapy if partners oppose medication or if opioids serve as a coping mechanism. Financial dependence and pressure from family or friends who disapprove of treatment or continue opioid use exacerbate these challenges. Fear of losing social or romantic support often outweighs motivation to seek help, leading to continued opioid use. Practical obstacles also reduce treatment uptake. Childcare responsibilities, transportation difficulties, financial constraints, and unstable insurance coverage limit access. Some women avoid prenatal care out of fear of detection, while internalized shame and guilt prevent many from seeking treatment even when they recognize the need (Table 1).

Provider-Related Barriers to Medications for Opioid Use Disorder

A significant barrier stems from provider hesitancy and discomfort in treating this population. Many physicians are reluctant to prescribe MOUD for pregnant individuals due to lack of experience or expertise in addiction treatment. This is compounded by unfamiliarity with screening and discomfort addressing OUD. Provider bias further exacerbates the issue, with some clinicians holding negative attitudes toward pregnant women with OUD. Some MOUD providers specifically avoid treating pregnant patients, viewing their cases as too complex or stigmatized.

Many providers face time constraints, while the practice burden of managing complex OUD cases discourages engagement. Obstetric providers in particular struggle with problems in screening for substance use and often lack the knowledge and understanding to properly counsel patients about MOUD in pregnancy. Stigma and misinformation permeate provider-patient interactions. Enacted stigma manifests as judgmental attitudes and maltreatment from healthcare professionals. Some providers give incorrect information about treatment options, while others maintain limited knowledge about OUD management in pregnancy (Table 1).

Health System-Related Barriers to Medications for Opioid Use Disorder

Systemic barriers hinder treatment access for pregnant women with OUD. Geographic disparities limit care availability, as rural areas often face provider and medication shortages, while urban clinics experience overcrowding. Structural obstacles include complex healthcare systems, clinic hours that conflict with childcare responsibilities, and a shortage of addiction specialists. Financial barriers also restrict access, including inconsistent Medicaid coverage, insurance denials, and racial inequities in access to medication-assisted treatment.

Legal and policy challenges discourage treatment-seeking, such as the criminalization of substance use during pregnancy, mandatory reporting to child protective services, and fear of legal consequences. These barriers are further compounded by gaps in support services. Many patients lack access to childcare, transportation, gender-specific counseling, and integrated mental health care. Reductions in services during the COVID-19 pandemic have worsened these disparities, leaving many pregnant women with limited access to treatment (Table 1).

Discussion

Despite the established efficacy of MOUD, a substantial proportion of pregnant individuals with OUD remain untreated. This review identifies key patient-, provider-, and system-level barriers to MOUD, highlighting not only the complexity of these challenges but also the opportunities for possible strategies.

Numerous barriers to MOUD among pregnant women originate at the individual level. One of the most significant barriers is the fear of stigma and judgment, which discourages many women from disclosing their opioid use or seeking treatment. This stigma includes external labeling by providers, family, and society, as well as internalized “infant-associative stigma,” where women blame themselves for fetal opioid exposure [33, 38–46]. Such stigma fuels isolation and delays treatment, worsening outcomes. However, stigma is a modifiable barrier: educating providers to offer non-judgmental, trauma-informed care can reduce enacted stigma and improve access. Supportive policies and community programs also encourage women to seek treatment without fear [47, 48].

Another prominent patient-level barrier is the fear of losing child custody due to involvement with Child Protective Services (CPS), often accompanied by legal consequences, which deters pregnant women with OUD from seeking MOUD [30, 43, 45, 49–52]. This aligns with similar studies demonstrating that the fear of family separation strongly deters treatment engagement. Anxiety about the potential detection of substance use and the resulting risk of losing custody of their children intensifies stigma and leads many women to delay or avoid care [53, 54]. Additionally, limited childcare options further restrict access to treatment. Interventions such as providing childcare support and implementing protective child welfare policies may help alleviate these fears, reduce stigma, and improve treatment uptake [30, 53, 55].

In addition to fears of stigma and child custody loss, this review highlights that concerns about fetal risks, especially neonatal withdrawal syndrome (NWS), significantly deter pregnant women with OUD from initiating or continuing MOUD. These worries often lead women to prioritize fetal health over their own treatment needs, further complicating efforts to engage them in care [30, 33, 38, 43, 48, 49, 51, 52]. Studies indicate that NWS affects approximately 52% of infants exposed to opioids prenatally, with risk increasing alongside higher maternal doses [56]. Additionally, long-term neurodevelopmental effects of prenatal opioid exposure have been documented [57]. Despite these risks, evidence consistently shows that the benefits of MOUD during pregnancy outweigh potential harms, underscoring the critical need for supportive care and patient education to address fears and promote treatment adherence. Informed counseling to mitigate concerns and improve maternal and neonatal outcomes is crucial [58].

Moreover, intimate partner violence (IPV) is often an under-recognized barrier to MOUD among pregnant women with OUD. Women in abusive relationships may avoid treatment when their partners oppose it, often due to misinformation or concerns about potential harm to the fetus [38]. Some women rely on opioids as a coping mechanism for abuse, which further complicates their willingness to engage in care. IPV often involves emotional, physical, or financial control, including interference with healthcare decisions and access to treatment. In particular, abusers may raise unfounded concerns about fetal risks or threaten retaliation, deterring women from seeking support due to fears of police involvement or child welfare intervention [59].

This review also highlights the influence of family and peer pressure, which can reinforce stigma and create emotional conflict for women who fear being judged or rejected by their social circle [51]. Similar studies confirm that stigma rooted in family and community disapproval increases isolation and leads to internalized shame, which may further delay care-seeking [51, 60]. These overlapping factors illustrate how IPV and social stigma together reduce autonomy and contribute to disengagement from MOUD. Strengthening community education, building supportive networks, and integrating trauma-informed care approaches can help reduce these barriers and improve access to treatment [19].

Furthermore, financial constraints, particularly the inability to pay for treatment or maintain stable insurance coverage, remain a major barrier to MOUD for pregnant women with OUD [40, 44, 45, 51, 61, 62]. Many rely on public insurance, which may offer only partial coverage or impose high out-of-pocket costs that make continued treatment unsustainable [19]. High deductibles, co-payments, and preauthorization requirements can lead to delays, deter initial engagement, or contribute to early dropout from care [63]. These findings align with previous research demonstrating that financial burden disproportionately affects low-income women, particularly those navigating complex pregnancies, contributing to disparities in treatment access and outcomes. Addressing these issues through expanded insurance coverage and reduced financial barriers is critical to ensuring equitable and sustained access to MOUD [64].

In addition to patient-level challenges, this review identified a range of provider-related barriers that limit access to MOUD among pregnant individuals. Among these barriers, limited provider knowledge and experience in addiction medicine emerged as the most consistently reported and modifiable factor. Obstetric providers, in particular, frequently report feeling unprepared to manage OUD due to limited training in addiction medicine, substance use screening, and counseling during pregnancy [30, 38, 41, 61, 65, 66]. Many obstetricians view OUD management as outside their scope and defer to addiction specialists, resulting in fewer than 20% receiving appropriate treatment [32]. In line with this finding, studies show that the absence of standardized protocols, and screening tools contribute to underuse of medications and low referral rates [58, 67]. This barrier stems from gaps in provider education and clinical preparedness. Targeted training, integration of addiction medicine into obstetric education, and the development of standardized care protocols can improve provider confidence and support consistent, evidence-based care. Implementing integrated care models in conjunction with clear clinical guidelines provides a practical framework for addressing modifiable barriers and increasing treatment uptake [30].

Furthermore, clinician stigma and bias also pose considerable barriers, although they are more complex to address. Some providers hold negative views or moral judgments about opioid use during pregnancy, which can lead to discrimination, misinformation, and reduced quality of care [29, 33, 38–41, 43–46, 51, 52, 61, 68, 69]. This report is aligned with other studies showing that negative attitudes toward substance use in pregnancy are linked to lower compassion and discomfort in providing care, which further exacerbates stigma [47, 70]. While attitudinal barriers remain deeply rooted, implementing compassionate, evidence-based care, stigma-reduction training, and improved provider–patient communication may help mitigate their impact and enhance access to treatment [58].

In addition to patient- and provider-related challenges, systemic barriers considerably hinder treatment access for pregnant women with OUD. Geographic disparities, in particular, continue to play a critical role in limiting access to MOUD among pregnant women [29, 30, 51]. Consistent with prior study, women living in nonmetropolitan areas face greater obstacles due to shortages of providers and treatment facilities, resulting in significant gaps in care availability [71]. While urban centers tend to have more comprehensive treatment resources, these areas often contend with overcrowded clinics and extended wait times, which can delay or deter engagement with treatment [19]. The persistent geographic and racial disparities highlight the need for targeted interventions to ensure equitable access to MOUD across all demographics.

Further compounding geographic disparities, structural barriers significantly impede access to MOUD for pregnant women with OUD. These challenges often arise from complex and fragmented healthcare systems, inflexible clinic schedules, and a shortage of addiction specialists. Navigating decentralized care networks adds to the difficulty, as pregnant women frequently encounter disconnected services and are required to coordinate care across multiple providers [30, 38, 40, 41, 52]. This aligns with prior research showing that obstetricians commonly defer OUD management to addiction specialists, which may delay timely treatment initiation [32]. Although telemedicine offers a promising approach to improving access, its potential is constrained by technological inequities and insufficient policy support. Therefore, addressing these systemic issues requires enhanced care integration, expanded provider training, and supportive policies [72].

Rigid clinic schedules frequently conflict with the caregiving responsibilities of pregnant women, making it difficult for them to attend regular appointments [49, 51]. These scheduling challenges are compounded by transportation barriers, health complications, and the demands of parenting, all of which disproportionately affect this population. Existing methadone regulations, which often require daily or near-daily clinic visits, place an additional burden on pregnant patients and may contribute to adverse maternal and neonatal outcomes. Similar study has highlighted the need for more patient-centered approaches, including flexible clinic hours and expanded access to take-home medications, as potential strategies to reduce logistical barriers and improve treatment adherence [73].

This review also highlights the limited availability of addiction specialists as a major barrier to MOUD for pregnant women with OUD. Another study supports this, noting a scarcity of specialists willing to treat this population, which restricts treatment options [74]. Compounding this issue, many obstetricians defer the management of OUD to specialists, resulting in a gap where few pregnant women receive timely and comprehensive treatment. Furthermore, the lack of integrated addiction and mental health services adds another layer of complexity, leaving many women without access to coordinated, holistic care [19]. Given the multiple barriers to treatment, additional risk factors, and serious outcomes linked with OUD in pregnancy, comprehensive programs have been developed to support this population. These programs address physical, mental, and social needs, as well as infant care, through on-site perinatal services. Integrated care models co-locate prenatal, postnatal, addiction treatment, and mental health services, reducing reliance on fragmented or referral-based systems. By enhancing engagement and retention in MOUD and strengthening continuity of care, these programs improve perinatal outcomes [75–77]. Studies show integrated models are linked to higher retention rates, with 69% of women continuing MOUD in the postpartum period [78]. In contrast, traditional prenatal care often fails to meet the needs of postpartum women with OUD, overlooking issues such as social support, mental health and recovery needs, and missing critical opportunities to continue MOUD [26].

Numerous studies included in this review also indicate that inconsistent Medicaid coverage and insurance denials remain significant barriers for women with OUD, often limiting their access to MOUD [38, 40, 43–45, 51, 61, 62]. These limitations are especially detrimental during pregnancy, when timely intervention is crucial to ensure the health and safety of both the mother and the developing fetus. Evidence suggests that states offering comprehensive Medicaid coverage for methadone report higher rates of planned opioid agonist therapy among pregnant women, underscoring the pivotal role of insurance policies in facilitating access to care. Expanding and stabilizing insurance coverage, particularly through Medicaid, is essential for improving treatment access and outcomes in this vulnerable population [79].

Legal and policy-related challenges also pose significant barriers to care for pregnant women with OUD. As several studies in this review indicate, punitive laws and insufficient policy protections, particularly the involvement of CPS, establish an environment of fear and mistrust that discourages women from seeking treatment [30, 33, 43, 45, 49–52, 71]. This is consistent with findings from another study showing that many U.S. states have enacted policies that criminalize substance use during pregnancy, which may deter women from engaging with healthcare services [80]. The Child Abuse Prevention and Treatment Act has been cited as a barrier, as it restricts pregnant women from engaging autonomously with healthcare providers, complicating their access to treatment [81]. Addressing these legal and policy issues is crucial to fostering a treatment environment that encourages engagement in care.

Studies in this review also report that pregnant women with OUD face substantial barriers to accessing MOUD, particularly due to gaps in support services such as childcare, transportation, and gender-specific counseling [30, 38, 40, 41, 52, 62, 65, 69]. These barriers are further exacerbated by stigma and socioeconomic hardship, both of which undermine access to and adherence with treatment. Prior study supports these findings, indicating that women with OUD, particularly those who are also primary caregivers, frequently experience stigma that discourages them from seeking care. Programs that offer childcare and family support are essential, as they enable women to engage in treatment without compromising their caregiving responsibilities [82]. A lack of transportation also prevents many pregnant women from consistently accessing OUD treatment. Patient navigation services that provide transportation support have been shown to improve continuity of care [83]. Women with OUD often have unique needs, including co-occurring mental health issues such as depression, which make gender-specific counseling and trauma-responsive therapy essential for effective treatment [82, 83].

Strength and Limitation of the Review

A key strength of this systematic review is its structured narrative synthesis of patient-, provider-, and systemic-level barriers to MOUD in pregnant women with OUD, systematically identifying and categorizing challenges to inform clinical and policy improvements. However, the absence of meta-regression limits the ability to quantitatively assess the impact of specific barriers. We recommend that future research employ meta-analytic techniques, such as meta-regression, to quantify these associations and inform data-driven prioritization of interventions.

Moreover, a notable limitation is the geographic concentration of included studies, with most conducted in the United States and only one from outside the U.S. This imbalance may have influenced the findings, as barriers to MOUD vary across healthcare systems, cultural norms, and policy environments. Consequently, the identified themes primarily reflect the U.S. context and may lack generalizability to other settings. We recommend future research in diverse regions to better capture the global range of barriers to MOUD among pregnant individuals.

Conclusion and Recommendations

This review highlights the complex interplay of barriers that can hinder pregnant individuals with OUD from accessing essential treatment. At the patient level, stigma, fear of custody loss, concerns about medication effects, and intimate partner violence may deter engagement with care. On the provider side, limited training in addiction medicine and implicit bias may affect clinicians’ readiness or willingness to deliver appropriate treatment. System level barriers, including fragmented care, geographic disparities, inadequate insurance and support services, and punitive policies, further limit access. Therefore, addressing these barriers may require a multifaceted approach that incorporates patient-centered care, health education, enhanced provider training, and systemic reforms aimed at reducing logistical challenges and aligning policies with current evidence-based practices.

Potential strategies to address patient-related barriers may include expanding health education for pregnant individuals and the broader community, particularly concerning the safety and efficacy of MOUD and the impact of stigma. Provider training that promotes awareness and non-stigmatizing communication is also likely to be essential. Collaboration with broader anti-stigma initiatives may further reduce stigma, especially toward pregnant individuals with OUD. Reducing fear of child custody loss may require targeted legal and policy reforms. Methadone regulations could be revised to allow more flexible dosing and expanded take-home options to better support caregiving responsibilities. Legal systems that disproportionately penalize women may be more effective if they shift from punitive to treatment-focused approaches. Child welfare policies, including the timelines established by the Adoption and Safe Families Act in the United States, may need to be reconsidered in light of current addiction science to help prevent premature termination of parental rights.

Improving access to MOUD for pregnant individuals in underserved areas may involve expanding the addiction medicine workforce, enhancing provider training, integrating services, and improving overall healthcare accessibility. Comprehensive training in OUD screening and management for obstetricians and primary care providers, particularly through self-directed online certification, could support safe prescribing of MOUD during pregnancy. Co-locating obstetric and addiction clinics can improve continuity of care, while telemedicine may reduce geographic barriers and expand the reach of specialists. Expanding insurance coverage for MOUD and equipping healthcare facilities with supportive resources, such as childcare and flexible scheduling, could play an important role in reducing barriers to care.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

B.A, B.A and D.Y were involved in formulating the research question, crafting the methods, and conducting article screening. The W.B, E.A and Y.A supported data extraction. D.G, M. E, S.A, A.M, S.Y and N.A provided critical reviews of the manuscript and assisted in revising the final version of the manuscript. All authors satisfy the authorship criteria, having significantly contributed to the work, participated in drafting and/or critically revising the manuscript, approved the final version for publication, and been sufficiently involved to take public responsibility for its content.

Funding

No fund was received for this work.

Data availability

Peer-reviewed articles that met the eligibility criteria are accessible in their respective publishers.

Declarations

Ethics approval

Not Applicable.

Competing interests

The authors declare no competing interests.