Early prenatal care and substance use treatment for pregnant women struggling with addiction increase the likelihood of a healthy mother, a healthy baby, and a healthy family.
Substance use disorder is the single largest factor contributing to the roughly 20 maternal deaths that occur in Oklahoma each year.
Many of these tragedies are preventable.
REPORT
PATHS TO
RECOVERY
A mixed methods report on pregnancy and
substance use in Oklahoma
I waited to go to the hospital as long as I could.
It was hard to be pregnant, knowing that you’re not going to get to take your baby home.
It was hard to be pregnant, knowing that you’re not going to get to take your baby home.
During my pregnancy, I was never really able to consider treatment, because I have a toddler too.
I was in fight or flight mode for myself and my kid.
I was in fight or flight mode for myself and my kid.
The path to recovery can be especially challenging for pregnant women in Oklahoma. Few treatment facilities cater to their unique needs, and some do not accept pregnant individuals at all. The dearth of options forces many women to choose between treatment and survival.
I think they really were trying to keep her from me [in the hospital], because as soon as I got admitted into my postpartum room, they didn’t talk to me about her.
They didn’t give me information like, ‘Hey, you can visit your baby in the NICU at these hours or this point in time.’
So I sat alone without my baby in the postpartum room until someone came to talk to me.
They didn’t give me information like, ‘Hey, you can visit your baby in the NICU at these hours or this point in time.’
So I sat alone without my baby in the postpartum room until someone came to talk to me.
Regardless of treatment enrollment, women suspected of using substances during their pregnancy often face stigma from Oklahoma’s medical providers and institutions. This keeps many from seeking what all too often would have been life-saving medical care.
I didn’t get any prenatal care. I was scared.
I didn’t want to tell anyone.
I was afraid to admit that I was using. Afraid to admit I was pregnant.
I didn’t want to tell anyone.
I was afraid to admit that I was using. Afraid to admit I was pregnant.
What’s worse, more and more Oklahoma women are facing charges of felony child neglect for using controlled substances while pregnant.
These charges are being brought based solely on a positive drug test at the hospital, sometimes in cases where the baby was born healthy and child welfare investigators found no evidence of child abuse or neglect
Executive Summary
Researchers, healthcare and social service providers, and public health experts are largely in agreement – when pregnant people struggling with substance use disorder (SUD) receive timely, non-judgmental care, outcomes are better for mothers, babies, and families.
In Oklahoma, however, there is a growing disconnect between proven best practice and the policies that govern its execution. It is a failure reflected in the health of the state’s mothers and infants.
In 2023, 11% of Oklahoma births were preterm, rising to 18% among Native Hawaiian and Pacific Islander and 15% among Black mothers.1KFF, “Oklahoma Maternal & Infant Health Data” 2025. Nine percent of all infants were born underweight;2Ibid. For Black infants, that rate was 16%. infant mortality rose from 5.9 to 7.1 deaths per 1,000 live births between 2020 and 2023. Severe maternal morbidity and mortality rates remain unacceptably high.3OSDH, “Severe Maternal Morbidity Among Oklahoma Mothers,” 2024.4KFF, “Oklahoma Maternal & Infant Health Data,” 2025.
Incidence of substance use disorder (SUD) also continues to rise in Oklahoma amidst a national opioid epidemic.6Ecker et al., “Substance Use Disorders in Pregnancy,” 2019 Unfortunately, a subset of that already vulnerable population is increasingly likely to be punished for their disorder – those who are pregnant.
The number of pregnancy-related charges brought against women in Oklahoma is growing; of the 227 cases researchers have identified since 2006, most (114) have occurred after June 2022.7Pregnancy Justice, “The Rise of Pregnancy Criminalization,” 2023; Pregnancy Justice, “Pregnancy As a Crime: A Preliminary Report on the First Year After Dobbs,” 2024 8Cheater, McAnallen, and Detty, “Criminalization of Pregnancy in Oklahoma,” 2025. Women have been charged with felony child neglect, which carries a potential life sentence, for testing positive for a controlled or illegal substance.9Pregnancy Justice, “Pregnancy Justice and Partners Apply to Oklahoma Supreme Court to End Prosecution of Pregnant Women for Medical Marijuana Use,” 2023.
As a data and policy organization committed to improving the health of women in Oklahoma, Metriarch has been working at the intersection of public health and state policy since our inception in 2018. Gaps this stark between proven health strategies and the realities our state’s most vulnerable face must be addressed, especially but not exclusively given their impact on women. Studies show that familial separation, especially through incarceration, can have long-term consequences, making it harder for future Oklahomans to break the cycles of poor health and poverty that plague our communities.
As part of its work with the Tulsa Fetal and Infant Mortality Review (TFIMR) project, Metriarch began investigating maternal substance use and its policy context. What began as a local inquiry revealed a broader, statewide crisis — one shaped not only by health challenges but also by punitive state responses.
Paths to Recovery, a multi-method report draws on interviews, observations, policy analysis, and public health data, is the result. Chapter 1 (“Walking the Path”) explores what it means to be pregnant with substance use disorder in Oklahoma. Chapter 2 (“Clearing the Path”) evaluates current policy and offers evidence-based recommendations to reduce harm and improve outcomes.
We understand that people with substance use disorder are part of a vulnerable population that faces unique risks of stigmatization and criminalization. These risks can impact quality of life, access to healthcare, and familial ties. In order to mitigate harm on an individual level, our research methodologies and analysis follow harm-reduction and trauma-informed principles, informed consent protocols, and ethical best practices.10The National Harm Reduction Coalition (NHRC) Harm Reduction Principles. Conversations from subject-matter and lived-experience experts were used to design and guide this work.
Summary of Key Findings
Stigma, fear of being charged with a crime, and lack of nearby healthcare providers prevent people with substance use disorder from receiving prenatal care. When Oklahomans with substance use disorder (SUD) discover that they are pregnant, the experience is often marked by fear. Participants in this study disclosed anxiety about interactions with medical care providers, familial separation, stigmatization, and fear of punitive measures. These factors often impacted their search for prenatal care.11Davis, Mina Dixon ““Bad Moms” and Powerful Prosecutors: Why a Public Health Approach to Maternal Drug Use is Necessary to Lessen the Hardship Borne by Women in the South,” 2018.
Those in rural areas faced the additional barrier of having to travel long distances to receive care. More than half of Oklahoma’s counties are maternal health care deserts with no obstetric providers or birthing hospitals.12March of Dimes, “Maternal Health Desert,” 2024. Without adequate transportation or financial resources, attending regular prenatal visits is nearly impossible.
Pregnancy makes engaging with substance use disorder treatment more complicated. Just as finding a prenatal care provider comfortable and capable of serving a client with SUD is a difficult undertaking, finding a SUD treatment provider who is prepared to treat a pregnant person presents challenges. Even for those who have the support and financial stability necessary to begin the treatment journey, it’s hard to know just where to begin.
In lieu of searching for specialized SUD services, pregnant individuals may seek to change their substance use behaviours on their own by, for example, stopping their opiate use and smoking marijuana throughout their pregnancy instead. This pattern illustrates 1) a desire to have a healthy and safe pregnancy and 2) the necessity of evidence-based harm reduction education for Oklahoma communities (and the providers that care for them).
Even participants who presumably had access to care often struggled to navigate complicated care systems. Finding a prenatal care provider was especially difficult when they were seeking someone offering stigma-free care with appropriate SUD knowledge. Many worried that they would meet with practitioners who didn’t understand their needs or might treat them disrespectfully. For some, these fears became reality during labor, when hospital staff were unkind or created barriers to bonding with their infant after birth.
Quick Stats
Births in Oklahoma with a positive substance use test
The Oklahoma Department of Human Services (OKDHS) has been collecting and disseminating information on substance-exposed newborns since 2011.16Oklahoma Department of Human Services, “Substance Exposed Newborn Report”, 2012
Their annual report includes the number of infants who tested positive for substances and the subset of those infants who experienced symptoms related to their exposure. On average, 1.3% of newborns in the state test positive for substance exposure at birth. The number of positive tests for substance-exposed infants has decreased yearly since 2021.
Although this report has the most comprehensive information on neonatal substance exposure in Oklahoma, it provides an incomplete picture.17 The figure “Births in Oklahoma with Positive Substance Test” compares the number of infants reported as testing positive in the state with the number of infants who were not tested or tested negative. This number is calculated by subtracting the number of substance exposed infants as reported by OKDHS from the number of infants born in Oklahoma as reported by the National Center for Health Statistics (NCHS) through CDC Wonder. We lack information on the number of infants that were tested and received a negative test as well as infants who tested positive for substance exposure at some point after leaving the hospital. Not every infant that is born in the state is tested for substance exposure, therefore incidence of substance exposed infants could be undercounted. The Comprehensive Addiction and Recovery Act (CARA) requires states to report the number of infants with prenatal substance exposure. U.S. Department of Health & Human Services Administration for Children and Families Administration on Children and the Youth and Families Children’s Bureau collect and share this data in an annual Child Maltreatment report. This report captures all infants under 1 year of age, while OKDHS only reports positive newborn substance exposure tests. The 2023 Child Maltreatment report indicates that 2,209 infants in OK were screened-in with prenatal substance exposure, while the number reported by OKHDS for that year is only 823.
Every infant born in the state is not subject to tests for substance exposure. Testing policies vary from county to county or even hospital to hospital. According to OKDHS, an infant is more likely to be tested if one or more of the following conditions apply: the parent received no prenatal care, the birth is occurring at a hospital far from the patient’s home, the infant is premature, there is placental abruption, patient’s medical history indicates substance use disorder or previous infant with positive test, or there are physical signs of using substances.18Oklahoma Department of Human Services, “Substance Exposed Newborn Report”, 2016
Pregnant admissions to substance use disorder treatment
The Substance Abuse and Mental Health Services Administration tracks admissions and discharges from Substance Use Treatment Services across the United States. When we examined data from Oklahoma, we found that an average of 2% of people admitted to substance use treatment services in Oklahoma each year are pregnant at the time of admission, nearly twice the national average of 1.1%.
The highest rate of pregnant admissions came in 2006 (3.6%), which is often considered the start of the first wave of our National Opioid Epidemic.19Ehley, 2019
The most common primary substances reported by pregnant people that year were methamphetamines (33.3%) and marijuana (20.4%).20Substance Abuse and Mental Health Services Administration, Treatment Episode Dataset: Admissions (TEDS-A), 2000-2022. Public Use Files (PUF). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Authors’ calculations.
The rate of pregnant admissions has decreased in most years since 2006. Notably, the decrease in the percentage of pregnant admissions in Oklahoma from 2009-2011 mirrors an overall drop in state admissions spurred by budget cuts at the state and federal level, which reduced funding for substance use treatment services and lengthened waitlists for care.21Graham, “Funding Cuts Hamper Addiction Treatments,” State of Addiction, ODMHSAS, 2012.
2022 (1.2%) was the first year with an increase over the previous year’s percentage (1.08%) since 2017. In 2022, the most common primary substances reported by pregnant treatment admissions were Methamphetamines (50%) and Heroin/ Other Opiates (20.3%).