Strengthening the standard of care for perinatal substance use disorders: reproductive health provider perspectives on training, integration, and system improvements

Abstract

Objective/background

Although perinatal substance use disorders (PSUDs) are increasingly prevalent among pregnant and postpartum (PPP) individuals, there is limited understanding of physicians’ perspectives on training needs and gaps in PSUD treatment. To reduce the negative impact of SUD on PPPs, identifying critical areas of intervention related to education and awareness for screening and treating PSUDs is critical. This study explored reproductive healthcare professionals’ (RHPs) perspectives on the necessary training to improve care for PPPs with PSUDs.

Methods

This study is an analysis of a cross-sectional survey of RHPs (n = 117). Inductive thematic analysis was conducted on free-text survey responses to identify RHP perspectives on training needs and strategies for improving care for PPP with SUD. Analyses were performed using Atlas.ti V 24.1.

Results

Participants were mostly White (77.8%) and female (93.2%) and included a broad sample of RHPs across multiple disciplines. Three primary themes were generated: (1) improving equitable access to evidence-based training, (2) prioritization of an integrated care network, and (3) addressing stigma in how care is delivered.

Discussion

The themes elicited from provider responses offer a framework for understanding opportunities to enhance care for PSUDs. Providers emphasized the need for more equitable access to evidence-based training to better equip clinicians to deliver high-quality care. They also described the importance of strengthening integrated care networks through collaboration among multidisciplinary professionals to improve care coordination and patient experiences. Addressing stigma in care delivery was identified as essential for fostering a more supportive treatment environment. These insights reflect provider perspectives and perceived priorities for system-level improvement rather than evaluated outcomes of specific interventions. Future research should examine the effectiveness of existing training and care models and identify strategies to enhance their accessibility and impact.

Introduction

Perinatal substance use disorders (PSUDs) are characterized by physiological, behavioral, and cognitive symptoms that promote continued substance use despite potential negative consequences and occur during the peripartum period. In this manuscript, “PSUD” refers specifically to substance use disorders occurring during pregnancy and up to one year postpartum; we use “SUD” only when referencing substance use disorders more generally. The rate of PSUDs has continued to increase in the United States [1]. Trends in both illicit and prescription opioid use during pregnancy have risen in recent years, and recent mortality statistics identify substance use as a contributing factor in 54% of pregnancy-related deaths, with mental health conditions also playing a significant role [2, 3]. PSUDs pose significant risks, including immediate health-related problems, emotional, and behavioral issues [4]. Maternal deaths related to PSUD are considered to be the most preventable pregnancy-related deaths [5]. However, most pregnant and postpartum people (PPP) who require PSUD treatment are unable to access it, and despite the numerous health risks of PSUDs, screening and care for PSUDs remain inadequate [6]. Multiple barriers, including stigma, fear of legal repercussions, and child welfare concerns, lead to underreporting and under-screening for PSUDs [7]. Despite the rise in prevalence of PSUDs, ongoing and targeted training in screening and referral related to PSUDs is minimal [8, 9]. Because PSUDs frequently cooccur with broader perinatal mental health conditions, including perinatal mood and anxiety disorders (PMADs), the training needs discussed in this manuscript encompass provider skills related to both PSUD-specific screening and management as well as identification of common co-occurring mental health concerns.

The general management of PSUDs in outpatient settings is already complex, and reproductive healthcare providers (RHPs) frequently report challenges in care delivery [10]. Broadly, RHPs encompass all clinical and non-clinical providers involved in delivering reproductive health services. Those who care for PPP are uniquely positioned to support PSUD treatment and recovery efforts. Including a broader sample beyond clinical care providers is critical, as community health workers, patient navigators, and other non-clinical professionals often play essential roles in care coordination, patient engagement, and linking PPP to needed treatment and recovery resources. Structural barriers, such as lack of Medicaid reimbursement, inadequate outpatient staffing, and limited standardized education for RHPs, further complicate PSUD management [11]. While primary care providers increasingly manage opioid use disorders, available treatment for other substances, such as stimulants and cannabis, remains inconsistent [10]. Although screening tools such as the Screening, Brief Intervention, and Referral to Treatment (SBIRT) approach have improved early identification of PSUDs, screening for PSUDs remains largely inconsistent [8, 9, 12]. Further, integrated PSUD management within reproductive care presents additional challenges. Despite recommendations from the American College of Obstetricians and Gynecologists (ACOG) that call for routine PSUD screening throughout the perinatal period, these recommendations are seldom followed due to provider training gaps and systemic barriers to care [13]. Previous research has also identified a lack of clinical guidelines for PSUD management across various RHPs [14, 15]. Patients frequently report negative provider interactions and high levels of perceived stigma, underscoring the need for improved education and bias reduction among RHPs [16, 17]. Further, the lack of comprehensive follow up care in the postpartum period can further exacerbate these issues [18]. Given these gaps in care, this study aimed to qualitatively assess RHPs’ perspectives on critically needed improvements for the PSUD care model, including considerations for co-occurring mental health conditions, and identify training needs to enhance screening, treatment, and referral practices. Addressing these barriers is critical to improving outcomes for PPP with PSUDs and their children.

Methods

Study design, sample, recruitment, and data collection

Data were collected as part of a larger cross-sectional survey administered via Qualtrics between June and October 2023, following Institutional Review Board approval (IRB2023-0374). The study aimed to assess reproductive healthcare professionals’ (RHPs) self-perceived comfort in providing SBIRT-centered care for postpartum patients with SUDs. We purposefully recruited a broad range of RHPs, including physicians (e.g., psychiatrists, obstetrician-gynecologists, family medicine providers), advanced practice professionals (e.g., midwives, nurse practitioners, occupational and physical therapists), licensed master social workers, licensed marriage and family therapists, and psychologists, to ensure broad representation and enhance generalizability of findings. Initial recruitment occurred at a national maternal mental health conference (n = 50), where participants were invited to complete the survey at a vendor table and received a $50 gift card as an incentive. To increase the sample size and professional diversity, additional participants (n = 67) were recruited via targeted maternal mental health provider email listservs with administrator approval; these participants were offered entry into a raffle to win one of two $100 Amazon gift cards. Because recruitment focused on maternal mental health conferences and listservs, the sample likely included providers who are more engaged in managing PSUD care, which may overrepresent mental health disciplines relative to the broader reproductive healthcare workforce.

Participants self-reported demographic characteristics (e.g., age, race/ethnicity, gender), profession type, time since graduation from their most recent degree program, the U.S. state in which their degree was obtained, and the state where they currently practice. They also reported their annual volume of postpartum patients, volume of patients with PSUDs, and whether they had received specific training in treating PSUDs. Participants provided brief open-ended responses to describe any prior PSUD-specific training. Additional open-ended questions elicited participants’ perspectives on (1) the most important steps needed to improve SPUD care delivery and (2) the critical training and resources necessary to enhance the current scope of practice in PSUD care. Participants provided informed consent electronically prior to beginning the survey, and all responses were collected anonymously. To protect confidentiality, any potentially identifying details within open-text responses or quotations were removed or generalized during data analysis and reporting.

Data analysis

All qualitative data analysis were coded by two coders, a doctoral-trained research specialist and a second-year medical student, both experienced in conducting qualitative research. The doctoral-trained coder had formal training in qualitative methodology, maternal health research, and mixed-methods study design, while the medical student coder had completed multiple qualitative research projects and received structured training in qualitative interviewing and coding. To enhance reflexivity and minimize potential bias, coders engaged in brief positionality reflections regarding their clinical and research backgrounds and discussed assumptions that could influence interpretation, incorporating these discussions into consensus meetings to promote analytic transparency. The training-specific short-answer responses were analyzed using content analysis to categorize the types of training participants self-reported. Each unique training description served as the unit of analysis. Two study team members independently reviewed all responses and developed initial categories based on recurring content. They then met to compare and refine categories through discussion until consensus was reached. This process produced a set of descriptive categories that summarized the types and modalities of PSUD-specific training reported by participants. Consensus agreement was achieved via discussions and total agreement on the final codes and subsequently generated themes.

The open-ended responses describing needed improvements in PSUD care and training were analyzed using inductive thematic analysis following the six phases outlined by Braun and Clarke: (1) familiarization with the data, (2) generating initial codes, (3) searching for themes, (4) reviewing themes, (5) defining and naming themes, and (6) producing the report [19]. Both coders first reviewed the responses to identify preliminary codes. They independently coded the full dataset, met regularly to compare interpretations, and refined the codebook through consensus discussions. Throughout the coding process, the team engaged in memoing, an internal analytical process involving the writing of reflective notes about the data and coding procedures to document emerging ideas, patterns, and insights. Memoing helped the researchers reflect on the data, refine their interpretations, and track the evolution of analytical thinking. In addition to memoing, the coders engaged in ongoing reflexive discussions about their disciplinary backgrounds, clinical experiences, and assumptions related to PSUD care to minimize bias and enhance interpretive rigor. The two coders met frequently to discuss their memos and notes, collaboratively refining the codebook and deepening their understanding of the data. After finalizing the codebook, all data were re-coded to ensure consistency, and themes were reviewed collaboratively until agreement was reached. Although formal data sufficiency was not assessed given the brief nature of responses, redundancy in concepts was noted across responses, suggesting thematic sufficiency. All qualitative analyses were conducted using Atlas.ti, and descriptive statistics were calculated using SAS version 9.4.

Results

Sample characteristics are presented in Table 1. A total of 117 RHPs participated in the study. The majority identified as female (93.2%), between the ages of 25–34 (27.4%), 35–44 (35.9), and 45–54 (25.6%), and White (77.8%). The sample included physicians (29.9% total, psychiatrists – 21.4%, obstetrician-gynecologists – 5.1%, family medicine – 3.4%), social workers (25.6%), advanced practice providers (21.4%), psychologists (11.1%), counselors (7.7%), and other RHPs (4.3%) (doulas − 2.5% and administrators − 1.7%). Participants were relatively evenly distributed across the four U.S. Census Bureau-designated regions [20]. Nearly all RHPs (97.4%) reported regular interaction with postpartum patients. While approximately two-thirds (65.8%) of providers had received some form of PSUD-specific training, over half (54.7%) reported caring for 20 or fewer patients with PSUD annually. When asked to self-describe training, among respondents, 34.2% reported receiving no formal training on substance use disorders (SUD), 29.9% indicated that SUD training was incorporated into their post-graduate or residency program, and 27.4% reported receiving only online or continuing medical education (CME)-based training. Table 2 summarizes the types of self-reported PSUD training participants described having received. These quantitative patterns, particularly the variability in PSUD-related training, the diversity of professional roles represented, and the relatively low annual PSUD patient volume for many providers, offer important context for interpreting the qualitative data. They underscore existing capacity gaps and help explain why participants described substantial needs for enhanced training, clearer care processes, and structural support. These quantitative characteristics were used to contextualize and interpret the emergent qualitative themes, particularly in understanding how differences in training exposure and clinical volume shaped participants’ perspectives on barriers, facilitators, and needed supports in PSUD care. The qualitative analysis generated three primary themes with five sub-themes centered around both individual and structural components of care delivery for PSUDs. Supportive quotes are provided in Table 3 to illustrate the themes and sub-themes.

Table 1.

Provides participant characteristics and demographics

Participant Demographics (n=117)
Measure	N (%)
Sex
Female	109 (93.2)
Male	8 (6.8)
Age
25–34 years of age	32 (27.4)
35–44 years of age	42 (35.9)
45–54 years of age	30 (25.6)
55 + years of age	13 (11.1)
Race
White	91 (77.8)
Black/African American	11 (9.4)
Other	15 (12.8)
Ethnicity
Hispanic/Latino	13 (11.1)
Not Hispanic/Latino	104 (88.9)
Profession Type
Social Worker (MSW/LCSW)	30 (25.6)
Licensed Marriage and Family Counselor / Associate Professional Counselor	9 (7.7)
PhD—Clinical Psychologist	13 (11.1)
MD—Psychiatrist	25 (21.4)
MD—Obstetrics/Gynecology	6 (5.1)
MD—Family Medicine	4 (3.4)
Advanced Practice Provider (NP/DNP/PA/OT)	25 (21.4)
Other (Doula, Healthcare administrator)	5 (4.3)
Time Period When Primary Degree was Obtained
2020–2023	26 (22.2)
2010–2019	59 (50.4)
2000–2009	20 (17.1)
1990–1999	11 (9.4)
1980–1989	1 (0.85)
United States Region Where Education/Training Occurred
West	19 (16.2)
Midwest	32 (27.4)
South	38 (32.5)
Northeast	28 (23.9)
United States Region of Current Practice
West	24 (20.5)
Midwest	33 (28.2)
South	35 (29.9)
Northeast	25 (21.4)
Regular professional interaction with postpartum patients?
Yes	114 (97.4)
No	3 (2.6)
Received training in SUD management?
Yes	77 (65.8)
No	40 (34.2)
Average self-reported annual volume of patients with SUD
1–10	42 (35.9)
11–20	22 (18.8)
21–30	15 (12.8)
31–40	6 (5.1)
41–50	5 (4.3)
50+	27 (23.1)

*(Ex. Doula, Healthcare administrator)

Table 2.

Describes the type of SUD training providers self-described having received

Self-described SUD training* (n = 117)
Type of Training Reported	N (%)
Training incorporated into post-graduate/residency program	35 (29.9)
Only received online training or through continuing medical education (CME)	32 (27.4)
Training was focused on models for treatment	4 (3.4)
No specific training, but currently treat patients with SUD	4 (3.4)
Training received/obtained specifically at a conference	3 (2.6)
Trained in risk factors and other intricacies of SUD	3 (2.6)
Trained in motivational interviewing tactics specific to reducing substance use	3 (2.6)
Training is specific only for prescribing drugs to treat SUD (MOUD)	3 (2.6)
Sought training programs in SUD unrelated to field of practice	2 (1.7)

*Percentages exceed 100% as respondents could describe more than one training option

Table 3.

Provides supplemental quotations

Supporting Quotes (n=117)
Theme	Relevant Quotes
Theme 1: Improving equitable access to evidence-based training	“Good, accessible low cost or free training.” “More training that is easily acceptable.” “Offering low cost or free that is accessible online such as webinars on demand. Providing more education about this in training programs for like medical students nursing students graduate students etc. Including a requirement for this type of training in the state renewal for licensure. Including the requirement for this type of training if you work in a hospital setting or in the VA.” “Education, regular trainings about the specific population as opposed to it being a small part of a large overarching training.”
Subtheme 1.1: Creating supportive environment for specializing in perinatal SUDs	“Enhanced incentives to grow pool of Addiction psychiatry professionals and substance-use informed professionals.” “More support and programs that are geared towards this issue.”
Subtheme 1.2: Increase training specific to managing perinatal SUDs	“More resources that support perinatal women and training other professionals who come into contact with perinatal women with SUDs” “Specific training on the intersection of SUD in the perinatal period.” “Increase provider knowledge and comfort with treating substance use disorder in pregnant and postpartum women due to long access times and limited providers with this knowledge.” “Increased access to perinatal mental health clinicians who are comfortable treating substance use disorders during the pregnancy or postpartum periods.”
Theme 2: Prioritization of an integrated care network	“I feel like trauma informed care and the involvement of a multidisciplinary team is important.” “Increasing cross disciplinary knowledge and collaboration across public health, mental health, substance use, and physical health providers…” “More interdisciplinary training and collaboration, SUD is a gap in my training that my training program has since addressed given trainee feedback, but I still seek more consultation and collaboration with due to less of my own training. During the postpartum period, concerns about CPS [Child Protective Services] reporting come up a lot from both patients and providers.” “A specific group of providers perhaps with patient advisors, that met to discuss on a monthly or even weekly basis. It should be led by experts who prioritize a welcoming attitude. It should be based on current science.”
Subtheme 2.1: Improving standard of care	“Training in medically assisted treatment for substance use disorders in pregnant and postpartum parents.” “How much time do you have? Insurance should provide for pre-and-post partum mental health and SUD screening and care. Women should receive paid time off work for birth and postpartum period - up to six months would be preferable. Mothers should be assessed for whether or not they have others around to help them with their children, and other aspects of daily functioning. If woman has history SUD, then she should be offered aftercare or preventative care, as well as education about effects of SUD on infants and young children.” “Weekly check-ins, screenings, and more than one 6-week postpartum visit, edu[cation] for pediatricians, and access to resources when a PHQ/EPDS screens positive.”
Subtheme 2.2: Targeted screenings are necessary for treatment	“Increased screening AND education to professionals about treating SUD in pregnancy/postpartum.” “Increased referral base and screening resources.” “Screen for postpartum mood disorders.” “Drug screens at OBGYN appointments and having support system (including OBGYN, midwife, etc.) be armed with immediate resources.”
Theme 3: Prioritizing the reduction of stigma in care delivery is essential to improving health outcomes	“Removing guilt and shame related to services and more education around risk factors and education.” “Bias training specific to this topic.” “The patient needs to know someone cares and wants the best for them and baby, adequate resources, adequate time.” “I think it’s important to also decrease stigma around SUD and asking for help, as well as normalizing the experiences.” “Asking every patient about their substance use in a non-confrontational way. Integrating mental health, OB and SUD care. Decreasing stigma and improving access. Encouraging a nonjudgmental approach during screening.” “This is a long way of saying that I believe destigmatization and non-judgment are critical, as is an approach of partnering with perinatal patients to engage in SUD treatment to benefit both members of the dyad.” “Assessment and diagnosis, referring to appropriate providers, working through this without bias and coming from a place of empathy and not casting judgement on this person.”
Subtheme 3.1 Harm reduction	“BH [behavioral health] support where patient is to support harm reduction and recovery, including access to MAT.” “Need for safety assessments; need for plan for opiate users to use MAT and abstain from illicit use; engagement in SUD programs, therapy. Supportive partner or families or other close persons.” “More specific behavioral health strategies for harm reduction focused intervention.”

Theme 1: Improving equitable access to evidence-based training

A central theme that emerged was the need to improve equitable access to evidence-based training for RHPs. Participants emphasized that disparities in access to high-quality training resources contribute to gaps in provider preparedness and, ultimately, in patient care. Several respondents highlighted the importance of embedding standardized, evidence-based PSUD training across all medical disciplines. As one participant stated, “Training [must] be REQUIRED as part of medical school and ALL residency programs, not just psychiatry and OBGYN.” Others stressed the need for more accessible training formats, particularly those that are cost-free or low-cost, to reduce financial barriers, with a respondent urging, “Increase in free or low-cost training for providers!!!” In addition to improving the availability of training, participants noted that increasing awareness of existing resources is equally important. Together, efforts to build and disseminate accessible, evidence-based training can enhance provider knowledge while advancing equity in clinical education.

Subtheme 1.1: Creating a supportive environment for specializing in perinatal SUDs

Participants emphasized the importance of cultivating a professional environment that actively supports and encourages specialization in PSUDs. Several respondents highlighted that increasing interest in this field requires more than just training—it requires a culture shift that values and uplifts those doing this work. Creating pathways that make this specialty more appealing and sustainable for providers was seen as critical to building workforce capacity. One participant noted the need to “talk more and to support those wanting to learn how to do this work,” underscoring the importance of mentorship, peer support, and institutional recognition.

Subtheme 1.2: Increase training specific to managing PSUDs

Participants expressed a strong need for training tailored specifically to managing PSUDs, with emphasis on evidence-based content addressing both maternal and infant outcomes. Several respondents called for foundational guidance on clinical care, including assessment tools, risk communication, and appropriate levels of care. As one participant noted, “I need a basic training that covers impact on parent and baby, risks, assessment tools and information about what level of care is appropriate for different scenarios.” Others highlighted gaps in training related to neonatal abstinence syndrome (NAS), neonatal opioid withdrawal syndrome (NOWS), and the effects of substance exposure, especially cannabis, during lactation. One provider emphasized the importance of “additional information about cannabis use and how to dispel myths [around safety of perinatal use] without shaming.”

Theme 2: Prioritization of an integrated care network

Participants highlighted the need to evolve the current model of care toward a more integrated, multidisciplinary network for managing PSUDs. Many providers reported feeling unprepared to deliver this specialized care, instead relying on referrals to more qualified specialty providers, such as those with addiction medicine training. As one participant explained, “I do not have the training or experience to provide care for perinatal clients with SUD. I could seek out further continuing education in this area but have chosen instead to refer to clinicians with both perinatal specialist and CADC [Certified Alcohol Drug Counselor] credentials.” Respondents emphasized that recognizing PSUDs as medical conditions and fostering collaboration across specialties are essential for improving access to care. As one provider noted, “[We need] recognition of SUD, acknowledging that SUDs are medical conditions, [and] must collaborate in a multidisciplinary fashion to ensure adequate access and support of SUD treatment.”

Subtheme 2.1: Improving the standard of care around perinatal SUDs treatment

Improving the standard of care for PSUDs requires expanding treatment models that address the unique needs of both the mother and baby. Participants stressed the importance of comprehensive care settings that can simultaneously manage mental health and addiction challenges. One respondent emphasized, “Then we need to provide patients with treatment settings that address their multiple mental health and addictions needs.” There was also a strong call for more treatment options that support keeping the baby with the mother during care. As noted by another participant, “There need to be more treatment options available including opportunities to keep the baby while in treatment.” Programs that promote maternal-infant bonding, such as those allowing in-room care, or offering flexibility to meet mothers’ needs, were identified as essential for improving outcomes. As one provider highlighted, “More programs that promote maternal/baby bonding and allow for in-room care or are flexible enough to meet the needs of mothers.” Prioritizing mom-baby dyad models can enhance both recovery and family health.

Subtheme 2.2: Targeted screenings are necessary for treatment

Participants emphasized that targeted and accurate screening is a foundational step in the effective treatment of PSUDs. Several participants highlighted that without proper identification, individuals may go undiagnosed or be misdiagnosed, leading to fragmented or ineffective care. They stressed that screening must be followed by a comprehensive, individualized diagnostic process to fully understand the nature, severity, and context of a patient’s substance use. This diagnostic clarity is essential for guiding tailored treatment planning and care coordination. As one participant succinctly stated, “Proper screening and then full and thorough diagnosis is needed for treatment,” underscoring the belief that early, precise identification is critical to ensuring patients receive care that is both appropriate and responsive to their unique needs.

Theme 3: Prioritizing the reduction of stigma in care delivery is essential to improving perinatal health outcomes

Participants emphasized that nonjudgmental, compassionate care encourages patients to seek help and engage in treatment. One respondent urged providers to approach patients “with an unbias[ed] nature… and a listening voice,” underscoring the importance of empathy in clinical interactions. Fear of legal consequences was also cited as a significant barrier to disclosure and care. As one participant shared, we must “reduce fear of legal repercussions if they disclose substance use and have support systems readily available.” Another emphasized the need for “nonjudgemental attitude by health care providers… legal protection for moms… [and] better treatment options,” highlighting the need for creating a safe, supportive environment where patients feel heard and protected to promote trust, engagement, and equitable access to care.

Subtheme 3.1: Harm reduction

Participants underscored the importance of integrating harm reduction principles into PSUD care. This approach emphasizes meeting patients where they are, offering nonjudgmental support, and prioritizing safety and dignity over abstinence-only models. As one respondent expressed, “Destigmatize, offer harm reduction, and see patients as whole people deserving compassionate care.”

Discussion

Findings from this study underscore significant gaps in the preparation and support of RHPs who care for PPPs with PSUDs. Together, the major themes identified (e.g. training equity, integrated care coordination, and stigma reduction) each highlight a critical direction for system-level improvement. Training equity points to the urgent need for standardized, accessible education across disciplines and stages of professional development; integration themes underscore the importance of coordinated, multidisciplinary models that center maternal health as foundational to family outcomes; and stigma reduction calls for embedding trauma-informed and harm-reduction principles into all aspects of perinatal substance use care. Participants emphasized that the current U.S. health care model’s disproportionate focus on infant outcomes, while well-intentioned, often reinforces stigma toward the mother and detracts from addressing her comprehensive health needs. RHPs in our sample highlighted that interventions that center maternal health and recovery as essential to improving both short- and long-term outcomes for families should be considered the standard of care in PSUD treatment and recovery. Maternal well-being must be prioritized as a core component of care, rather than treated as secondary to infant health [21].

Across respondents, training related to PSUDs varied considerably, revealing significant inequities in professional preparation. Nearly one-third (29.9%) of participants reported no formal training in managing PSUDs, while an equal proportion (29.9%) indicated that such education occurred only during post-graduate or residency training. Additionally, 27.4% reported receiving only online or continuing medical education (CME)-based training, indicating a potential reliance on self-directed or supplemental learning opportunities rather than structured curricula. These patterns highlight inconsistent and delayed training pathways that may hinder provider competency and confidence in PSUD care. The variability across disciplines underscores participants’ calls for accessible, standardized, and equity-focused education integrated early in professional development to ensure all providers are adequately prepared to support perinatal patients with PSUDs.

Participants called for universal, evidence-based, and accessible training to be integrated into the foundational education of all health care professionals, not solely those in psychiatry or obstetrics. Low-cost and no-cost training modalities were specifically endorsed to reduce financial barriers and promote equitable access to professional development. Fostering a supportive environment prioritizing easily accessible training related to specialization in PSUD care could serve as a critical strategy to build workforce capacity and resilience [22]. Perinatal Quality Collaboratives (PQCs) offer one model for advancing these goals by facilitating structured, team-based efforts to improve maternal and infant care. PQCs operate at the state or multistate level to identify clinical processes in need of improvement and implement evidence-based strategies for rapid change. Participants perceived that such collaboratives could serve as platforms for disseminating standardized PSUD training and promoting best practices across diverse healthcare settings [23]. Given their statewide reach and established infrastructure, PQCs also represent a viable mechanism for embedding standardized PSUD training into system-level policies, such as through integrating PSUD treatment approaches into state licensure or continuing education requirements and coordinating uniform training implementation across clinical sites via PQCs. Consistent with recommendations from national organizations such as ACOG, participants emphasized that efforts prioritizing maternal well-being, enhance provider–patient communication about substance use, and support continuity of care are essential to improving outcomes and reducing disparities in perinatal care [13].

The quantitative profile of the sample provides important context for interpreting the qualitative themes that emerged. Descriptive findings revealed that respondents represented a diverse range of reproductive healthcare disciplines and varied substantially in their prior exposure to SUD-related training. Nearly one-third reported receiving no formal training, while others gained experience only through post-graduate programs or continuing education opportunities. This variability likely shaped participants’ perspectives, with those not reporting structured PSUD education emphasizing the need for more accessible, standardized, and early-stage training opportunities. Similarly, the mix of clinical and non-clinical providers informed broader calls for integrated, multidisciplinary care models that extend beyond traditional medical frameworks. Taken together, the quantitative characteristics of the sample help explain the strong emphasis participants placed on training equity, care coordination, and stigma reduction as key priorities for improving perinatal SUD care.

Improving screening practices for maternal mental health emerged as a particularly salient recommendation. Participants underscored that targeted, accurate screening is foundational for the effective treatment of PSUDs, as inadequate identification can result in fragmented or ineffective care. Integrating validated, perinatally focused mental health screeners alongside substance use assessments may facilitate earlier recognition of clinical needs [24]. Participants emphasized that screening should be followed by a comprehensive, individualized diagnostic process to ensure treatment plans reflect the nature, severity, and context of substance use. Approaches must be trauma-informed, culturally responsive, and non-punitive to avoid exacerbating fear of legal consequences or provider bias [25]. Training providers to recognize implicit bias and standardizing protocols were identified as key strategies to promote equity and reduce stigmatizing practices. When embedded within a structured referral pathway, equitable screening can serve as a critical link to timely, multidisciplinary care.

Participants also emphasized the value of integrated care networks as an optimal model for managing PSUDs. Across disciplines, RHPs advocated for systems that support collaboration between medical, behavioral health, and social service providers. RHPs described an ideal care pathway begins with routine screening during perinatal care, followed by warm handoffs to trained specialists who offer wraparound services, including medication for opioid use disorder (MOUD), perinatal mental health treatment, case management, and family support. Co-located or tightly coordinated services that address both maternal and infant needs, particularly those that enable maternal-infant bonding and allow for children to remain with their mothers during treatment, were viewed as essential to optimizing outcomes. Participants described current systems as fragmented and under-resourced, with care often siloed and reliant on informal or inconsistent referral networks. RHPs suggested that evolving the current model of care, such as utilizing novel methods for screening that reduce the burden of care on RHPs, can be a solution to both improving care access and increasing the timely receival of that care [26]. Operationalizing such integrated care networks would likely require expanded reimbursement for care coordination, sustainable funding for multidisciplinary teams, and adoption of formal care pathways or hub-and-spoke models that link obstetric practices with behavioral health and social service agencies [26].

Stigma reduction emerged as a central priority among participants, who emphasized that judgmental attitudes and fear of punitive consequences deter patients from seeking help. RHPs advocated for a health care environment rooted in empathy, legal protection, and trust-building. Stigmatizing practices, such as mandatory reporting without clear therapeutic benefit, were seen as undermining the therapeutic alliance and perpetuating disparities. Instead, care models must promote safety, dignity, and patient autonomy [27]. Additionally, RHPs consistently endorsed the integration of harm reduction principles into PSUD care. Harm reduction approaches acknowledge the complex realities of substance use and prioritize the patient’s goals, safety, and dignity over abstinence-only models [28]. Strategies such as naloxone distribution, safer substance use education, and support for continued breastfeeding when clinically appropriate were identified as practical and compassionate interventions. Participants emphasized that stigma reduction must extend beyond the clinical encounter to inform state-level policies, including revising mandatory reporting requirements to distinguish between substance use and substantiated harm, expanding legal protections for pregnant patients seeking treatment, and aligning reporting practices with evidence-based, non-punitive public health frameworks [27–29]. Embedding these principles within perinatal care delivery is essential to meeting patients where they are and fostering sustained engagement in care.

Limitations

This study’s findings must be viewed in light of several limitations. First, data were collected as part of a survey, and as such responses were relatively brief and did not allow for as in-depth analysis compared to a structured interview. The study sample was a relatively homogeneous group of mostly White females and used convenience sampling techniques and conducted in a very short time frame (< 5 months). Additionally, PSUD care practices were self-reported, and as such reporting bias could have influenced participant characteristics. We also specifically recruited providers from maternal mental health conferences and listservs, groups which likely are more engaged in managing PSUD care, and as such our findings might not be generalizable to other health professional groups. This recruitment strategy may have overrepresented mental health disciplines and providers with greater familiarity or investment in behavioral health integration. As a result, perspectives related to stigma, trauma-informed care, and integrated behavioral health may be amplified in our findings, while the views of obstetric or primary care providers with limited exposure to PSUD care may be underrepresented. As a result, the themes identified, such as the strong emphasis on stigma, integrated behavioral health, and the importance of care coordination, may reflect the priorities and perspectives of this more highly engaged subset of providers rather than the full spectrum of reproductive healthcare professionals. Nonetheless, these participants’ perspectives offer valuable insight into system-level gaps and opportunities for strengthening PSUD education, care integration, and workforce support.

Conclusions

This study highlights the urgent need to restructure PSUD care by prioritizing maternal health, expanding evidence-based training for a broad range of providers, and fostering integrated, multidisciplinary networks. RHPs overwhelmingly endorsed approaches that reduce stigma, support harm reduction, and improve screening for maternal mental health. Addressing these gaps requires coordinated policy, education, and system-level interventions. Advancing equitable, person-centered care for postpartum individuals with PSUD is critical to improving long-term outcomes for both mothers and their infants.

Author contributions

L.H. collected the data. L.H. and B.S. conducted the analyses. All authors reviewed the manuscript.

Funding

This work was supported by the Clemson University CU SUCCEEDS initiative. Sponsors had no role in study design, data collection and analysis, or manuscript development and submission.

Data availability

The data that support the findings of this study are available from the corresponding author, [LAH], upon reasonable request.

Declarations

Ethical approval

This study was approved by the Clemson University Institutional Review Board (IRB2023-0374).

Consent for publication

The participants provided informed consent regarding publishing their data.

Competing interests

The authors declare no competing interests.