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A mixed methods report on pregnancy and substance use in Oklahoma
When Ashley22This vignette is comprised of multiple interviews from women who shared their stories with us for this study, parts of the story have been added for clarity and flow. We use this approach to show the similarities between participants as well as to protect their confidentiality and anonymity. See the About Metriarch section of this report for information on our approach to research and summarization. thinks back on her last pregnancy; the first thing that comes to mind is that it all went by so fast. As is often the case,23McCarthy, et al. 2018. it took about a month for Ashley to realize she was pregnant. In those early weeks, life went on as normal. She went to work, spent time with her partner and friends, and sometimes used controlled substances, mostly marijuana and occasionally unprescribed opiates.
When she started feeling queasy and spotting, she thought her period was coming soon. She smoked marijuana to help curb the nausea. Later, a friend recommended that she take a pregnancy test.
When it came back positive, she was terrified.
Drug use had been a part of Ashley’s life since she was in high school. Now, several years after graduating, she felt incapable of managing her day-to-day life without some sort of substance use.
She didn’t want to tell anyone about the pregnancy. She was afraid to talk to an OB, afraid to discuss her substance use, afraid to imagine the future. Even after Ashley told her family and friends she was expecting, she found it hard to accept it herself. It was hard to accept being pregnant with a child she might not get to keep.
Marijuana continued to help Ashley with her nausea, regulated her mood, and allowed her to cut back on opiates for the duration of her pregnancy. She did some research online – marijuana was unlikely to hurt her baby. Fear of judgment and shame kept Ashley from verifying this information with a clinician or service provider.
Substance use treatment didn’t cross her mind. Growing up, she had never seen anyone view illicit substance use as a problem, as long as you were making it through the day. Even if her habits did get out of hand, what could she do? If she took time away to get treatment, she could lose her job or housing. She was already behind on bills. She didn’t have the financial stability or flexible employment to survive that.
Even on days she understood she needed help, she knew the path to recovery was more intense than she could afford to risk.
Basic needs had to be top of mind: What the hell am I going to do to not be sick tomorrow? What do I need to wake up and get through the day?
It felt like she was going through everything alone.
The intersection of pregnancy and substance use disorder is an area that demands the attention of public health experts, criminal justice advocates, and proponents of reproductive justice.24Reproductive justice is a human rights framework with four core pieces: “as the human right to maintain personal bodily autonomy, have children, not have children, and parent the children we have in safe and sustainable communities.” Sister Song Women of Color Reproductive Justice Collective. Law Students for Reproductive Justice and National Women’s Law Center, “If You Really Care about Criminal Justice, You Should Care about Reproductive Justice!” This is particularly true in Oklahoma, a state which routinely ranks among the worst for both women’s health and female incarceration.25Commonwealth Fund, “State Scorecard on Women’s Health and Reproductive Care (Oklahoma)”, 2024 26Beaman et al., “Quantifying Adverse Childhood Experiences in Oklahoma With the Oklahoma Adversity Surveillance Index System (OASIS): Development and Cross-Sectional Study,” 2023 Substance use disorder (SUD)27Also commonly referred to as ‘addiction.’ has been labeled one of the “most stigmatized and undertreated chronic medical conditions.”28Barber and Terplan, “Principles of Care for Pregnant and Parenting People with Substance Use Disorder.” The disease is defined by an inability to control the use of a substance (legal or illicit); use that disrupts the ability to meet living needs (housing, occupation, family care, etc); or use that harms one’s health.29Lipari and Van Horn, “Children Living with Parents Who Have a Substance Use Disorder.”
For most, the path to recovery from SUD is a winding one, shaped by interlacing features of social, medical, and legal systems. For pregnant women30See Disclaimer on Gendered Language. with substance use disorder,31Often referred to in this report as pregnant people with substance use disorder (PPWSUD) these systems can work in confusing and sometimes paradoxical ways. For example, although pregnancy is often referred to as a key window for intervention, it is also a time in which individuals become more vulnerable to both stigma and punishment for their disorder.32Egart,” The Criminalization of Mental Illness and Substance Use Disorder: The Criminalization of Mental Illness and Substance Use Disorder: Addressing the Void Between the Healthcare and Criminal Justice Addressing the Void Between the Healthcare and Criminal Justice Systems Systems,” 2024 33Davis, ““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,” 201
At the core of this paradox is the belief that SUD is not a public health crisis to be remediated by increased access to services, but a moral failing that can be controlled through punitive measures.34Ibid. 35Ecker et al., “Substance use disorders in pregnancy: clinical, ethical, and research imperatives of the opioid epidemic,” 2019 Evidence suggests that this perspective actually perpetuates the conditions it wishes to eliminate. Findings from research on the relationship between punitive policies and newborn substance exposure indicate that odds of prenatal exposure increase in the immediate and long-term aftermath of introducing these policies.36Faherty, “Association of Punitive and Reporting State Policies Related to Substance Use in Pregnancy With Rates of Neonatal Abstinence Syndrome,” 2019 A strong example of this phenomenon comes from Tennessee, which brought down the “velvet hammer” on PPWSUD in 2014 by adding maternal substance use to its statute on fetal assault.37Davis, ““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,” 2028 38A similar sentiment to the one researchers from this project saw while presenting preliminary results to the OK Legislature during an interim study in 2023. The law was allowed to sunset after just two years. An analysis of births in TN and surrounding states during this time period revealed that the policy was “associated with an increase in out-of-state births, potentially putting pregnant people and their infants at greater risk.”39Choi et al., “The Implementation of the Tennessee Fetal Assault Law and Its Association With Out-of-State Births Among Residents of Tennessee,” 2023
Research from various settings across the US has shown that these mothers face stigma, dangerous policies, and inadequate care systems along their path to recovery.40Ibid. However, very little research on this issue has been conducted in Oklahoma. Our state is home to a dangerous trifecta of substandard reproductive health outcomes,41Common Wealth Fund, “Commonwealth Fund 2024 State Scorecard on Women’s Health and Reproductive Care (Oklahoma).” high infant mortality,42March of Dimes, “Maternity Care Desert.” and high rates of female incarceration;43Cox, “Prioritizing Oklahoma Mothers: Recommending Rehabilitation and Recovery Rather than Punishment for Pregnancy.” providing a uniquely rich context for exploring the lived experience of PPWSUD. In 2021, 87.5 of every 10,000 hospital deliveries in Oklahoma were accompanied by a severe maternal morbidity,44OSDH, “Severe Maternal Morbidity Among Oklahoma Mothers.” 2024. and between 2018 and 2021, the maternal mortality rate was 30.3 per 100,000 live births.45KFF, “Oklahoma Maternal & Infant Health Data” 2025.
The number of people in Oklahoma diagnosed with substance use disorder during pregnancy has more than quadrupled since 1999.462022 Oklahoma Maternal Health Morbidity and Mortality Annual Report, Oklahoma State Health Department Thankfully, treatment options for pregnant and parenting women have expanded in recent years. In 2020, only a third of the state’s substance use treatment facilities indicated they had programming for pregnant or postpartum women. That proportion grew to 41% in 2021 and 42.8% in 2022.47National Directory Of Drug And Alcohol Abuse Treatment Facilities, Substance Abuse and Mental Health Services Administration (SAMHSA) However, merely having targeted programming does not mean that pregnant and postpartum women are in fact receiving treatment. Pregnant women still make up a small proportion (~2%) of total female substance use treatment admissions in Oklahoma each year.48Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS)
When it comes to addressing challenges faced by mothers like Ashley, state law and its administrative and judicial interpretation are sometimes at odds with approaches favored by addiction specialists and public health experts. Current policy creates pathways for the state to act as both a protective structure and a “void that swallows people in the throes of mental illness and substance use disorder.”49Egart,”The Criminalization of Mental Illness and Substance Use Disorder: The Criminalization of Mental Illness and Substance Use Disorder: Addressing the Void Between the Healthcare and Criminal Justice Addressing the Void Between the Healthcare and Criminal Justice Systems Systems,” 2024. Which route a family takes is often left to the discretion of local law enforcement, healthcare providers, and social workers, which has resulted in stark differences in how struggling mothers are treated across the state.50Cheater, McAnallen, and Detty, “Criminalization of Pregnancy in Oklahoma,” 2025.
The mounting issue reached the state’s highest courts in 2024, when the Oklahoma Court of Criminal Appeals requested that lawmakers address ambiguity in state law around the criminality of substance use during pregnancy.51Pregnancy Justice, “Pregnancy Justice and Partners Apply to Oklahoma Supreme Court to End Prosecution of Pregnant Women for Medical Marijuana Use” 2023 52The State of Oklahoma v Amanda Camp Aguilar, No. Case No. S-2023-575 (The Court of Criminal Appeals of the State of Oklahoma 2024). During the 2025 state legislative session, some policymakers attempted to answer the call by introducing bills that would have made marijuana use during pregnancy a crime – with or without a medical license.53See House Bill 1750 (2025) and House Bill 2737 (2025). Neither received a hearing. See Brianna Bailey, “It’s legal in Oklahoma for pregnant women to use medical marijuana. A bill aims to change that,” The Frontier, January 21, 2025.
As the second chapter of this report, Clearing the Path, elucidates, this judicial opinion and legislative response are unsurprising to those familiar with pregnancy criminalization in Oklahoma.54The term pregnancy criminalization distinguishes criminal charges related to pregnancy or punitive policies that are intensified because someone is pregnant. The state ranks second in the nation for the number of pregnancy-related charges brought against women. The number of such cases is growing exponentially.
National advocacy group Pregnancy Justice has identified 100 cases of pregnancy criminalization in our state over the past 16 years.55Pregnancy Justice, “Pregnancy As a Crime: A Preliminary Report on the First Year After Dobbs,” 2024. 56Ibid. Of those cases, 68 occurred between June 2022 and June 2023 alone.57Ibid. 58Cheater, McAnallen, and Detty, “Criminalization of Pregnancy in Oklahoma,” 2025. New legislative pathways for criminalizing substance use during pregnancy would contribute to the growing number of charges and prosecutions, potentially worsening health outcomes for both mothers and infants.59Sung W. Choi et al., “The Implementation of the Tennessee Fetal Assault Law and Its Association With Out-of-State Births Among Residents of Tennessee,” 2023.
This report has two chapters: 1) Walking the Path: Lived Experience of Substance Use and Pregnancy in Oklahoma and 2) Clearing the Path: A Blueprint for Better Supporting Families Impacted by Substance Use Disorder. This chapter paints a picture of what it is like to live in Oklahoma as someone who is pregnant with SUD. We use various state and federal quantitative data to supplement insights from interviews with subject matter experts and those with lived experience. The second chapter provides a detailed evaluation of relevant policies and legislation before outlining evidence-based recommendations for improving outcomes for families impacted by substance use.
Data used in this study were collected via interviews between March and August 2023. Researchers designed the study methodology with attention to participant vulnerability to stigmatization, criminalization, or emotional distress (see ethical considerations in Appendix B). When scheduling each interview, the interviewer would share an informed consent statement with the participant via email (Appendix A). Before each interview began, the researcher would ask if the interviewee read the informed consent document, understood it, or had any questions. Any questions were answered at this time. If the participant read and understood the document, the interview would begin. If the participant had not read or did not understand the document, the researcher would review the document with the interviewee and provide clarification. The interview would begin after the participant acknowledged understanding of the document.
Interview subjects came from a broad range of racial and age demographics. Subject matter experts came from a variety of backgrounds and encompassed many different levels of leadership. All lived experience participants had had at least one birth in Oklahoma in the past five years.60More information on participants in this study can be found in Appendix D. Each interview took place via Zoom video call. In total, 11 interviews were conducted. All interviews were uploaded to Dovetail for transcription and analysis. Once automatic transcription was completed, a member of the research team listened to the audio and corrected transcription mistakes, as necessary. Both inductive and deductive codes (referred to as ‘tags’ in Dovetail) were created to analyze interview transcripts.
Quantitative data were collected from public use files and reports from the Substance Abuse and Mental Health Services Administration (SAMHSA), Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS), Oklahoma Department of Human Services (OKDHS), and Centers for Disease Control and Prevention (CDC). These data were stored in a private drive and spreadsheet. Data on substance use treatment admissions from SAMHSA were stored and analyzed using R.61Authors’ R code is available upon request for further inquiry into the topic or study replication. Various members of the team contributed to quantitative analysis and data visualization. 62Most visualizations were created using Flourish. which were reviewed by Metriarch’s Data Analyst for accuracy.
After her water broke, Ashley waited as long as she could before heading to the hospital. She labored at home, pacing as her partner urged her to go to the Emergency Room (ER). When she eventually gave in she was rushed to the ER and seen immediately.
She told them about her substance use as soon as she could. Hospital staff were understanding. She felt safe.
When the doctor arrived Ashley pushed a few times, then baby Olivia was here.
The questions seemed to come immediately after Ashley had stopped pushing. “When was the last time you smoked? Did you drink during your pregnancy?”
Ashley wanted time to bond with Olivia. She wanted skin-to-skin. She wanted to spend the golden hour with her new baby girl. Her smile dropped as Olivia was kept apart from her and the questions kept coming.
She felt defeated. She just needed to know how her baby was doing.
Eventually, Ashley was taken to the postpartum floor while Olivia was taken to the neonatal intensive care unit (NICU) for breathing issues.
Ashley still wonders if hospital staff simply wanted to separate them, because they wouldn’t tell her about Olivia. They wouldn’t talk about her. She didn’t get information about when she’d be able to visit the NICU or see her baby again.
After she was settled, the room cleared, and she sat alone in her postpartum room until someone came to talk to her.
Olivia was one of over a thousand infants to test positive for substance exposure in Oklahoma when she was born in 202063Oklahoma Department of Human Services, “Oklahoma Substance Exposed Newborn Report” 2020, but her mother Ashley was not one of the mere 200 pregnant women in the state who recieved SUD treatment.64SAMHSA, “Treatment Episode Dataset: Admisisons” 2020 The next section empirically explores why mothers like Ashley struggle to access appropriate care in Oklahoma.
As identified in the introduction of this report, pregnant people with substance use disorder face unique challenges to accessing appropriate healthcare and services. In this section, voices of lived-experience and subject-matter experts are presented alongside secondary data to explore the question: What does it look like to emotionally and logistically navigate these complex systems in Oklahoma?
Findings are divided into two categories:
Prenatal care is an important component of healthy pregnancies.65 Oklahoma State Department of Health, “Oklahoma Maternal Health Morbidity and Mortality Annual Report.”This care becomes even more important when the pregnancy is accompanied by health concerns that may cause complications.66El-Mohandes et al., “Prenatal Care Reduces the Impact of Illicit Drug Use on Perinatal Outcomes,” 2003 Despite this, PPWSUD are more likely to delay or avoid receiving prenatal care.67Klie et al., “Integrated Care for Pregnant and Parenting People With Substance Use,” 2023 Data from our interviews align with established public health research findings which explicate the negative impact of punitive measures for SUD on prenatal care reception among PPWSUD.
The experiences of participants like Ellie68While Ashley is a composite of multiple participants, all other other names in this section are pseudonyms for individuals who spoke with us about their experiences. show the role stigma and fear can play in perinatal decision-making for Oklahomans.
Ellie is a mom of three young children. She says her first pregnancy was really good because she hadn’t “experimented with drugs yet. So I went to all my prenatal care from day one and [the baby] was born very healthy. [That] pregnancy was probably my healthiest and my most, like, enjoyable because I knew I was pregnant. Everybody knew I was pregnant. I got a baby shower. It was just fun preparing for her.”
To Ellie, attending all of her prenatal visits seems to follow naturally from the statement that she hadn’t started to use substances. The excitement of Ellie’s first pregnancy is rooted in being able to acknowledge the pregnancy and share her joy with others. Ellie didn’t feel the need to hide from her loved ones or avoid healthcare – “everyone knew.” Preparing for the baby became something “fun” that she was able to experience with friends and family.
A stark contrast is illustrated in Ellie’s description of her next pregnancy.
In the years between her first and second pregnancies, Ellie had started using methamphetamines. This time when she found out that she was pregnant, it was harder to accept. She was afraid. “I was honestly scared because I was using, and I didn’t really know how to, like, go about talking about it with anybody.” So she hid the pregnancy as long as she could.
At this point, Ellie was most afraid of “admitting that [she] was using and knowing… right off the bat, they would take the baby at birth and [she] would just have to go through that process.” She found it difficult to accept being pregnant with a baby she thought she’d never get to know or bond with.
Ellie: I was just afraid to go [to the doctor] and admit that I was using. And I really wasn’t excited about that pregnancy either. Because I was dealing with addiction. So it was just really hard. I was really depressed the entire time because I wasn’t trying to really admit that I was pregnant, even though everybody knew I was because, again, I wasn’t going to be able to keep her. So it was hard to be pregnant, knowing that you’re not going to get to take your baby home.
Interviewer: You talked about knowing that you wouldn’t be able to keep her. Where did that understanding come from?
Ellie: Just my own actions and knowing, like, mentally knowing that, like, I can’t stop and, like, physically knowing that, like, I couldn’t. It was just hard, not having any help. Not, like, knowing who to ask for help or just being so embarrassed of what I was doing and stuff like that. So I just tried to like hide.”
Sophia recounted a similar experience with her second pregnancy. Like Ellie, Sophia explains that her lack of prenatal care was a direct result of her substance use by saying, “I didn’t have any stability to kind of help that recovery process along while I was pregnant with my youngest kid, and so I didn’t have any prenatal care with my last kiddo.”
The Health Stigma and Discrimination Framework by Stangl et al.69Weber et al., “Substance Use in Pregnancy,” 2021 provides a helpful model for understanding Ellie and Sophia’s decision-making processes. Stigma invalidates experiences of SUD as a mental health disorder by framing “addiction as a personal choice reflecting moral failing and deficiency in will power.”70Ibid. For many of our participants with lived experience of pregnancy and SUD, this time in their lives was guided by multiple interacting levels of stigma.71Ibid. At a structural and institutional level PPWSUD face discriminatory policies, lack of appropriate treatment options, and laws which intensify punitive measures based on their intersecting identities as pregnant women72These measures are also gendered; they are associated with societal expectations of what a ‘good mother’ looks like. who use substances. Meanwhile, criminal justice advocates stress that “a woman’s pregnant status and the biological fact of her pregnancy should not subject her to prosecution in instances where nonpregnant women or men would not be.”73Law Students for Reproductive Justice and National Women’s Law Center, “If You Really Care about Criminal Justice, You Should Care about Reproductive Justice!” 74Pregnancy Justice, “Pregnancy As a Crime: A Preliminary Report on the First Year After Dobbs.”
Interpersonally, stigma can contribute to new or greater “judgment and shame from those previously participatory or tolerant of their substance use, leading to further isolation.”75Weber et al., “Substance Use in Pregnancy.”
It may also color PPWSUD’s relationships with health care providers. Participants like Ellie and Sophia made decisions with the expectation that they would be judged and shamed by providers. Ellie internally reproduces the same stigma she is afraid of encountering at the doctor’s office. Her internalized stigma manifested as a feeling of embarrassment that made her want to hide.
When an individual with SUD does receive prenatal care it is not guaranteed that they will be supported throughout their perinatal journey. When speaking about her second pregnancy, Emma told us, “I did feel very supported by my doctor in general until the end. And then, like, two weeks before my delivery date, she was like, ‘Oh, by the way, I have a vacation scheduled for your due date, but I didn’t think you would carry full-term so I didn’t see the point of, like, talking about it…’ That kind of hit me out of left field because I was high risk and you know, she had been there the whole time and then she wasn’t.”
Someone with substance use disorder (SUD) might struggle to accept their pregnancy because they do not feel ready or able to parent a first or additional child. They may also fear encountering stigmatization upon seeking prenatal care or substance use treatment.
Individuals may have difficulties changing their substance use habits, even when they have a desire to do so, if they lack the necessary support and guidance for recovery.
Prenatal care may be delayed or avoided altogether because of fear of criminalization.
Individuals may struggle to find accurate information on how to care for their pregnancy without appropriate prenatal care. They may not know how to safely reduce their substance use while caring for other children, working, paying bills, etc.
At every stage there is a strong need for healthy social relationships, which may involve cutting people out of their lives. For some, healthy relationships are cultivated in the treatment space.
Some individuals are unfamiliar with labor/delivery processes when they arrive at the hospital. They may delay seeking care for fear of judgmental providers and systems involvement.
People with substance use disorders often fear interactions with hospital staff due to discrimination and stigma they may encounter in healthcare settings. Care providers must act proactively to send clients to hospital spaces where they will be treated with respect.
Breastfeeding has been proven to improve babies’ mental and physical health. For new mothers battling substance use, it often serves as a way to gain confidence in their ability to provide for their child as well as added accountability.
Newborn care for mothers with SUD and in recovery often involves added measures to keep families safe, healthy, and together. Sometimes, it includes navigating custody challenges and other institutional involvement, which can affect stress levels, finances, housing stability, and more.
In addition to the life-changing adjustments a baby brings, new mothers recovering from SUD are making a fundamental change in the way they respond to stress. They must juggle both without reverting to maladaptive behavior patterns and continuing to prioritize their recovery.
Harm reduction education was a predominant theme throughout interviews with both parents and care providers.
Prenatal care is a critical opportunity for trust-building, education, and care coordination with PPWSUD. When individuals are afraid to seek that care, they share long-term impact with their loved ones.76See Familial Impact. Our interviews show that individuals in Oklahoma also require prenatal care (and primary care) providers to fill a gap that they are not always trained in – harm reduction.
Harm reduction is both a theoretical approach and a programmatic technique for addressing substance use treatment.77Wright et al., “Implementation and Evaluation of a Harm-Reduction Model for Clinical Care of Substance Using Pregnant Women.” Common misconceptions of harm reduction posit that it simply means increased access to substances and drug paraphernalia, which will lead to increased substance use and higher crime rates.78Hoss, “Legalizing Harm Reduction.” 2019 In actuality, the core tenets of harm reduction practices include “safer use, managed use, abstinence, meeting people who use drugs ‘where they’re at,’ and addressing conditions of use along with the use itself.”79Harm Reduction Coalition. “Harm Reduction Principles.”
This approach accepts that it is “impossible to eliminate all health harms,” and instead focuses on practical actions to increase safety.80Hoss, “Legalizing Harm Reduction.” 2019 Common harm reduction services include overdose prevention sites, clean syringes, drug testing kits, and overdose reversal drugs.81Ibid. Implementation of these services has resulted in the prevention and reversal of thousands of overdoses as well as the reduced spread of diseases such as HIV and Hepatitis C.82Ibid.
What qualifies as “safer use” during pregnancy looks different depending on the person and their substance use behaviors.83Harm Reduction Coalition. “Harm Reduction Principles.” Interviews revealed a pattern of self-regulated safer use by clients and indicated a need for evidence-based education on what qualifies as safer use.
Rebecca, a case manager for an organization that works with family disruption at an Oklahoma-based agency, summarized the need for comprehensive harm reduction by noting the tendency for clients to take harm reduction into their own hands during pregnancy:
“A lot of my parents that I’ve heard – like a lot, like an extreme number of them – who were, like, either in that postnatal or even beyond, you know, they can reflect back on… when they found out they were pregnant and their babies were about to be born. They were like, well, you know, ‘I just drank alcohol. I didn’t use heroin during that time,’ or, ‘Well, I decided just to use THC all day every day instead of ‘fill in the blank.’’ Right? And so, like, we know that these [substances] are not great for baby, you know, that we know that these are not great for baby, but… the misinformation just feels right because they didn’t have the accurate information on what was actually safe… [It] feels like we could have done something different. Like, someone somewhere could have given you some direction instead of just leaving you to your own, like, what Google says, you know?”
Underlying Rebecca’s statement are the ideas that 1) some substances are worse than others when used during pregnancy and that 2) pregnant people change their substance use behaviors during pregnancy with 3) the intent to minimize fetal harm. Rebecca’s observations are in line with current public health research, which indicates that pregnant people who use illicit substances are likely to decrease their substance use during pregnancy.84Yale, “Where is the Gender in Harm Reduction? Workshop.” This interview and others with lived experience participants made it clear that there is an education gap for Oklahomans who want to change their substance use behaviours during pregnancy—one that primary care physicians and obstetric care providers could be trained to fill.85American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice, “Opioid Use and Opioid Use Disorder in Pregnancy,” 2017
Whether or not an individual is able and willing to receive prenatal care, they are often pushed into interaction with the Oklahoma healthcare system during labor and delivery.
Like many PPWSUD,86Cox, Alex B. “Prioritizing Oklahoma Mothers: Recommending Rehabilitation and Recovery Rather than Punishment for Pregnancy.” OKLAHOMA LAW REVIEW 76 (2024). Ellie waited until the very last minute to head for the hospital during her labor. When asked about the delay in seeking care, Ellie said, “I was totally trying to have that baby in the garage because I was terrified. I was. And I’m glad I didn’t, because [when] I went to the hospital I hemorrhaged with her and I could have died.”
Her baby’s father and his mother urged her to get care and eventually successfully convinced her to go. She had reached 8 centimeters dilated by the time she made it to the hospital, and her baby was born soon after.
Unlike Ellie, Ivy felt that she was met with judgment and unkind behavior when she arrived at the hospital for her second birth. She was ignored when she told her nurses that she “dilated fast” in her last birth and felt like things were moving on quickly. She didn’t understand what would cause the hospital staff to treat her the way they did, and said, “I don’t know if it’s because of my skin color. I don’t know if it’s because I’m young… I don’t know what it is.”
Ivy shared that after disclosing her status in a prison diversion program for women with SUD, “that’s when [hospital staff] really just started judging me… [I] don’t really know how to, like, really explain that. It was just like, terrible, like, they ruined my whole mood.”
As her labor progressed, Ivy received an epidural that didn’t relieve her birth pain.87The failure rate for epidurals varies from 8- 23% because there is no commonly accepted definition for the term. Ivy was among this small percentage of birthing people who did not feel satisfied with the efficacy of pain relief provided. Around 10 minutes after a cervical check (where a nurse measured her at 6 centimeters dilated), Ivy started to scream from the pain. A nurse came in and Ivy told her she needed to push; the baby was coming. Instead of listening to her, the nurse dismissed her and told her she didn’t feel that way, but when she attempted a cervical check, she found that Ivy’s baby was already crowning and rushed to call the doctor.
Immediately after the baby was out, hospital staff began to ask questions about Ivy’s previous drinking and substance use. Although she had refrained from drinking during the pregnancy, their confusing and unrelenting questions overwhelmed her. It felt like she was being attacked and kept from her baby.
“I’m just an emotional person. So once I feel like I’m being attacked, like, I feel like I have to defend myself. And I don’t want to come off rude or disrespectful to someone… especially like my elder or something. So it was hard for me to like, just be comfortable in that space. Like, it was very uncomfortable. Just being there… after I had him I was really just ready to go home. Like I didn’t even like care about what they was talking about anymore. Like, I just wanted to go home.”
Despite the feeling of being attacked, Ivy tried to be respectful in her conversations with hospital staff, aware that there was a power imbalance to navigate.88Scholz et al., “‘Not an Afterthought.’”2018
An imbalance that would make anyone uncomfortable, let alone someone like Ivy, who was especially vulnerable to stigma and unjust systems involvement.89Ibid. Ivy’s identity at the intersections of womanhood, youth, Blackness, and substance use disorder made her a distinct target. Not only is maternal mortality higher for her age and race, but “low-income women of color in the South [disproportionately feel] the burden of this trend toward punitive sanctions for maternal drug use.”90Davis, “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
As a doula, Emma has gotten to experience how Oklahoma’s hospital systems treat PPWSUD from two perspectives. Her practice focuses on people who have similar stories to her own, and she knows how important it is to feel safe and respected during labour and delivery. Birth is a vulnerable period that forever becomes part of someone’s life story, and Emma wants to safeguard that period for her clients.
“This hospital specifically in Tulsa, is my favorite for women with substance use disorders. because they treat you with kindness, they treat you with respect. They treat you like you’re a valuable human being. You’re not treated like trash, because you have substance use disorder.”
Her stories of the hospital make their commitment to “kindness” clear. When Emma brought back a client who’d birthed there a couple of years prior while in active addiction, “half of the team recognized her. And all the nurses said, like, I’m so proud of you, and who you are today.” Emma makes it clear that it isn’t a guarantee that you’ll be treated with dignity anywhere you go as a PPWSUD. That experience has to be carefully sought out and curated.
Emma noted that not all hospitals (or care providers) are equal when it comes to receiving informed and non-stigmatizing care.
“Whenever we as moms and pregnant women [with SUD] go into the hospital to deliver, the nurses don’t understand that there’s multiple levels to this, that a safety plan is to put something in place to ensure that nothing does happen. They like that there’s levels to DHS involvement, they see DHS, and they will instantly not treat them great.”
Emma’s observations bring to life the anxieties of PPWSUD who wanted to avoid stigmatizing and judgmental perinatal care. Emma notes that some nursing staff are not aware of the complexities of DHS involvement or how safety plans function as a preventative tool. 91Safety plans are a set of documents that are designed to support health care and care coordination for parent and infant. 92See Clearing the Path for more insight on safety plans and plans of safe care.
Unfortunately, Sophia’s first labor and delivery experience provides a clear example of the necessity of safety plans when caring for PPWSUD. Sophia began misusing substances at age 12 and continued to do so until she found out she was pregnant with her first child. She was able to stop using on the day that she found out she was pregnant.
A few times during the pregnancy, she felt an urge to use, but each time she says it was easy to remind herself, “We’re pregnant, we can’t do that.” She made it to term and her 23-hour labor ended in a c-section, which resulted in being prescribed pain pills – her drug of choice. The next section details Sophia’s postpartum experience and return to use. A safety plan or screening for substance use history may have contributed to a more effective approach to Sophia’s pain management after her c-section.93Substance Abuse and Mental Health and Services Administration, “Evidence-Based, Whole-Person Care For Pregnant People Who Have Opioid Use Disorder.”
A year later, Sophia was preparing to deliver her second baby, and everything was different. Sophia had not been able to stop using substances during this pregnancy, “because with heroin, I call it the devil… it literally makes you feel like you’re dying, if you don’t have it.” She also had not received prenatal care because of her use. She avoided going to the hospital until there were complications, and her water broke early.
“Maybe [if I] would have went to a different hospital, it would have been different, but whenever I first got there, the people who initially saw me were very kind and understanding… The first thing that came out of my mouth was, ‘I’ve been using heroin and meth with this pregnancy.’ And the first things out of their mouths were, ‘That’s okay. We have a lot of women that come in here saying that.’ At that point, I was like, ‘Okay, I’m in the right, in the right place, they’re gonna take care of my kid.’”
Sophia immediately disclosed her substance use to hospital staff and was fortunately met with compassion and respect. Staff were able to gain Sophia’s trust, and she felt good putting her care and the care of her infant in their hands. After the baby was born Sophia recalls bonding with one nurse in particular while another was “awful towards” her.
“[The nurse] probably either has had somebody with a substance abuse issue, or [she] herself knew what it was like. She was very understanding and caring and, like, anytime I was upset or breaking down because of my addiction, she would be the one there… she’d get on my level and just talk to me about the fact that it’s going to be okay and [say], ‘We’re going to do the things that we can do to help you with this…’ [Another nurse] was just very mean… her whole demeanor was awful towards me, like I was a POS,94Colloquial short-hand for “piece of shit.” I didn’t need to be here, I didn’t need to have kids like, I just am scum, and I need to go die, right? Like, that’s what I got from this lady’s demeanor. And so every time she was there, I would try to be outside of my room as long as I possibly could before I came out, because I didn’t want her anywhere near me.”
During her time in the hospital after her second birth, Sophia experienced two opposing ends of the spectrum of care that PPWSUD often receive. While one nurse treated her with the respect, dignity, and compassion that she (and every birthing person) is deserving of, another made it clear through their interactions that she looked down on Sophia and her decision to parent.
Interviews revealed the postpartum period as another inflection point for our participants with lived experience.
Two conversations, in particular, illustrate how this phase intersects with SUD and recovery.
As stated previously, following a substance-free pregnancy, Sophia’s first birth experience led her to return to using substances. She explains:
“I had to have a c-section with [my oldest child]. And so they have to give me – well, they didn’t have to – but they provided me with pain medication, which was my drug of choice at that time. And so at that point, it just kind of went downhill. So I didn’t stop after that, you know, prescription ran out. I didn’t have the tools that I have now. Because, you know, if I had them, I wouldn’t have gone right back out. I would have had a safety plan in place. I would have had somebody monitoring what I was doing with those pain pills. So I didn’t have any of that in place. So, after about two months of having my oldest child, instead of pain pills, I went to heroin because that was a lot cheaper at the time. And so stayed on heroin. Well, even after I was pregnant with my second kiddo, I didn’t stop using with him. It was a lot harder while using heroin to stop than it was with the pain pills with my oldest kid. So I attempted to stop with you know, the MAT clinics. I went to one at that time.” – Sophia
Sophia’s postpartum experience is not uncommon. 1 in every 300 women who undergo a cesarean delivery will have trouble using and stopping their pain medications as prescribed.95Bateman, Brian T., Jessica M. Franklin, Katsiaryna Bykov, Jerry Avorn, William H. Shrank, Troyen A. Brennan, Joan E. Landon, et al. “Persistent Opioid Use Following Cesarean Delivery: Patterns and Predictors among Opioid-Naïve Women.” American Journal of Obstetrics and Gynecology 215, no. 3 (September 1, 2016): 353.e1-353.e18. https://doi.org/10.1016/j.ajog.2016.03.016. Around 75% heroin users report having substance use issues with prescription opioids before using heroin.96Davis, “‘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.” Sophia attempted to use medications to treat her substance use disorder, which is a recommended best practice.97Substance Abuse and Mental Health and Services Administration, “Evidence-Based, Whole-Person Care For Pregnant People Who Have Opioid Use Disorder,” 2023 However, without adequate support, safety planning, healthy coping skills, and other tools she eventually gained in recovery, Sophia was not able to make the changes she wanted to at that time.
Emma was further along in her recovery journey when she found out she was pregnant for the second time. During pregnancy, she attended therapy and treatment services, eventually graduating months before giving birth. Emma had one major goal for postpartum: breastfeeding and bonding with her baby in a way that she wasn’t able to do with her first child. She was successful and said the event changed her life. “There’s nothing comparable to, like, sitting there with them, nurturing them through yourself that way. God intended… her [to] look into my eyes [while I’m] looking into her eyes… [it] was just the most amazing thing I could have ever experienced in my life.”
This time period was life-changing in more ways than one. Breastfeeding was “added accountability” for Emma’s recovery journey: “If my milk needs to be clean, I can’t mess up because I have to feed my baby. And so that didn’t even click until we were finishing nursing.” After a few years of breastfeeding, Emma was well along the path of recovery. She had different friends, new coping mechanisms, and even listened to different music. When her breastfeeding journey ended, she had a moment of self-doubt before realizing that she no longer felt the same desire to use. Emma had come quite a long way from the disordered substance use that had been a part of her life for so many years. The next section explores the journey to recovery after early exposure to substance use.
Most participants described early exposure to substances as a key factor in the later development of substance use disorder. Some encountered alcohol and benzodiazepines before entering high school. This early contact contributed to a sense of normalcy around illicit use, making it more difficult to recognize when the behavior became disordered.
As adults, participants like Emma found it hard to imagine a life which did not involve some form of substance use.
“When I was 14, my family collectively decided that I was getting older and that I needed to drink with them so that they could see how I behaved whenever I was under the influence, to know if I was safe to go to parties and stuff… from that point forward, it was like if everybody was doing stuff, I was now included, because [I was] the youngest.”
Emma recalled that she did not have an interest in substance use and parties at this age. Outside of school, she socialized by attending church and youth group. However, when she was introduced to alcohol and other substances by family, things changed.
“It felt like to me, I was doing normal kid things because until I was 14 or 15, I did not realize that not everybody had a spout of using things. I didn’t realize that there were families where their parents had never drank and [had] never done drugs in their whole life, because everybody around me did at some point.”
Throughout Emma’s childhood, she saw her mother and brother engage in illicit substance use. By the time they involved her, she thought it was normal. From this point until she was approaching 30 years old, Emma said she was “never abstinent from substances.”
Ivy started drinking around age 14 to cope with childhood trauma. When she thought back to ages 14 to 18, she said, “ I was, like, drinking, like, almost every other day. And, like, I was really just drinking because to, like, get over, like, pain and just to feel, like, numb.” After being abused, Ivy didn’t feel like she had people who would listen to or help her. Drinking was a way to get through life without healthy coping mechanisms.
The trend of (re)introduction to substances through family and friends continued into adulthood for many participants. After a period of financial instability that led to an eviction, Emma and her young child moved in with her mom. The move resulted in Emma returning to illicit substance use. She shared: “It was probably six to eight weeks before I realized that she was using meth. And then probably another four weeks before I started using with her.”
Around two weeks into an extended hospital stay after giving birth to her third child, Sophia left with a friend to use substances. Although she “didn’t want to use meth,” her friend did not have opiates (which were her drug of choice). When she got to the hospital, a urine analysis revealed to hospital staff that “this person [is having] a harder time than [they] originally thought.” Sophia lost custody of her children but was connected with substance use treatment services.
Individuals may struggle to identify disordered behaviors as unhealthy due to long term normalization of substance use within families and in other important social relationships.
Participants from our study often identified someone who first introduced them to the concept of substance use disorder and recovery. This interaction is not usually well-received because at this point, they have not identified their substance use as a problem.
It may take months to years for an individual to accept that they have a disorder. This may come with shame or stigma that needs to be addressed in a safe way.
Individuals may encounter the concept of recovery many times before they decide it is the appropriate step for them.
Often, relationships are the site of normalization of substance use. If an individual decides to attempt self-guided substance use reduction, they will have a more difficult time managing initial steps into recovery without appropriate social support.
Self-guided changes in substance use behavior are difficult to manage and at times unsafe. Support from care providers is needed to advise individuals on how to appropriately manage triggers and safely navigate behavior change.
Individuals need support to feel safe enough to seek treatment. This is a major disruption in their life, and it can cause financial and familial insecurity.
A key part of the work done in recovery is building empathy for one’s past and removing stigma associated with their disorder.
At this stage, participants begin to actively engage in therapy and substance use treatment. They learn what works for them and what doesn’t. They may also receive their first diagnosis of a mental health condition.
Many seek out healthy relationships at this point, sometimes for the first time. Some have never had a supportive relationship that did not involve substance use.
Once individuals learn their triggers, they can begin to find less harmful ways to respond to them or avoid them altogether.
Individuals leaving recovery must reevaluate their existing social networks in order to safely navigate returning to their lives and continuing recovery after treatment ends.
It is important that individuals and care providers understand the prevalence of return to use (relapse) and work together to develop safety plans, which can prevent relapses or ensure they are navigated safely if they do occur.
After leaving treatment, it is up to the individual to utilize the tools they gained to navigate the stresses of life and safeguard their mental health.
From identifying disordered behavior to entering treatment, pregnant Oklahomans face unique challenges when seeking mental health treatment for a substance use disorder.
Treatment options for pregnant and parenting women in Oklahoma appear to be expanding. In 2020, only a third of the state’s substance use treatment facilities indicated they had programming for pregnant or postpartum women. That proportion grew to 41% in 2021 and 42.8% in 2022.98National Directory Of Drug And Alcohol Abuse Treatment Facilities, Substance Abuse and Mental Health Services Administration (SAMHSA)
Further research is needed to understand if these facilities are actually meeting the needs of pregnant people with substance use (PPWSUD) in our state. In the early phases of our research, a search for pregnant/postpartum SUD treatment programming in Oklahoma yielded a directory by Drug and Alcohol Rehab Headquarters, which used data from the Substance Abuse and Mental Health Services Administration (SAMHSA).99Drug and Alcohol Rehab Headquarters, “Oklahoma Drug Rehab” 100Substance Abuse and Mental Health Services Administration (SAMHSA), Behavioral Health Services Information System (BHSIS): National Directory of Drug and Alcohol Use Treatment Facilities In 2023, 53 programs were listed. The programs were densely gathered around Tulsa and Oklahoma City, but sparse in rural areas. Researchers randomly selected and called several treatment centers.101Methodology and memos from these treatment center calls can be found in the Appendix. Included among the special programs for “pregnant/postpartum women” in Oklahoma were men’s only facilities and phone numbers that led to dead ends.102Check out Appendix C for more insights from these calls.
Ultimately, even if a facility does have targeted programming, there is no guarantee that pregnant and postpartum women are benefitting from it. Pregnant women still make up a small proportion of total admissions (an average of 2.02% per year).103Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS)
Stories from Sophia, Ivy, and Ellie reveal some of the emotional barriers that keep PPWSUD from accessing treatment.
In addition to fear and stigma, substance use was so normalized for them that participants found it hard to identify when something was wrong. Ivy said she never thought that she might have a problem until she found herself in a prison diversion program where she was able to attend Alcoholics Anonymous support groups. Despite her SUD, Ivy said, “I never [saw] myself as alcoholic. Like, yeah, I’d never just looked at it like that, because [I] always told myself, like, ‘Oh, I could stop, you know.’” Although she was able to successfully stop drinking while pregnant, it was difficult without professional support and was not a long-term solution to addressing her disorder.
Many of our lived-experience participants did not have the vocabulary to understand or knowledge to treat their SUD until they were compelled to enter substance use treatment through, for example, prison diversion. Like Ivy and Emma, they assumed their substance use was normal. Emma recalled that when she first started “to get in trouble, [her aunt] was on the phone with everybody, [saying] ‘I need somebody to help her, she needs help.’” Emma’s “trouble” at this time largely centered around an abusive relationship where she feared calling for help because her friends, who were using or selling substances, might get caught in the crossfire. Instead, Emma said she would, “get arrested [to] be away from him,” until she got out. He would then find her again.
Her aunt tried contacting a prison-diversion program, and after Emma didn’t qualify, her aunt set her up with a “doctor’s appointment” that turned out to be an inpatient intake assessment. Emma said, “I remember not being completely honest with them. And then at the end of it, they told me that I was not qualified for inpatient treatment.” Later, when Emma was facing charges that could have resulted in prison time, her aunt continued to advocate for her. She called the previous prison diversion program to tell them, “She’s prison bound now, like, you guys need to accept her.”
Emma’s story mirrors that of other PPWSUD participants in two critical ways:
On the other side of SUD treatment, Emma says that her experiences give her a lot of grace for other PPWSUD who simply are not ready for help.
“Being [a doula] as a recovering addict… I feel like that’s where my benefit is. I don’t take it personally. I know that if you’re not ready, you’re not ready. I also know that you’ll come in here and do whatever you have to do to make it be okay and then leave and do whatever you want. Because I’ve done that, too.”
Emma has been on the other side, trying to appear okay and minimizing the extent to which her substance use was disordered or harmful. She is willing to work with clients who are at that point in their journey and support them until they are ready, whenever that time comes.
“I know that there was a lot of people who wanted me to be ready,” she said. “And I just wasn’t.”
Care providers validated this perspective.
Norah, director of a substance use counseling agency, told us that people with SUD need multiple touchpoints with people who care throughout their lives before being ready to engage and seek recovery for themselves. She shared that some may need up to 20 “touches” before feeling ready.
Norah’s love for her profession came from knowing, “I’ll be able to touch some people today, just because I’m here. Sometimes I don’t even need to say a word because they [just need to] see people in recovery, and that’s the miracle of this job.”
In the end, when someone is given the opportunity to receive SUD treatment and is ready to start down the path to recovery, the positive impact cannot be understated. As Emma said about her experience: “A lot of people would be like, ‘Oh, I get a second chance at life,’ and I’m like, this is really my first.”
Understanding the familial impact of SUD in Oklahoma is crucial to ensuring policy benefits PPWSUD and their families.104Find our detailed policy recommendations in the chapter Clearing the Path. Exploring how substance use during pregnancy affects families begins at the hospital immediately after birth — the first time both parent and/or baby can be tested for prenatal substance exposure.
Not everyone who gives birth is screened or tested for substance use. Protocol around how and under what circumstances a drug test is administered varies across the state and may be influenced by provider bias.105Though experts, including those involved in drafting recommendations from SAMHSA, also advise against universal testing. Testing is not a definitive way for hospital staff to determine if someone has SUD, cannot always identify some substances, and discourages PPWSUD from seeking care. Substance Abuse and Mental Health and Services Administration, “Evidence-Based, Whole-Person Care For Pregnant People Who Have Opioid Use Disorder,” 2023. The preferred mechanism for testing newborns is via meconium, their first stool, which provides a much longer window of exposure than a urine test.106Weber et al., “Substance Use in Pregnancy,” 2021. So long, in fact, that even if an individual discovered they were pregnant as the first trimester was coming to a close and quit smoking marijuana, the exposure would likely show up on a test at delivery.107Window is about five months.
Experts argue that “the role of specimen testing should be to monitor treatment goals, and positive testing should prompt treatment implementation or adjustment rather than discharge or punishment.”108Weber et al., “Substance Use in Pregnancy,” 2021. SAMHSA only recommends testing in order to identify substances when “objective findings” are needed, as is the case when someone is actively showing signs that they may be intoxicated, which may affect the health of parent and baby, or there are other immediate concerns about the health of the individual and their pregnancy. Agency guidance also urges providers to “recognize that discrimination and stigma can lead to inequities and approach the decision from an unbiased perspective.”109Substance Abuse and Mental Health and Services Administration, “Evidence-Based, Whole-Person Care For Pregnant People Who Have Opioid Use Disorder,” 2023
These stipulations are important because after a positive substance exposure test, care providers’ hands are tied. At that point, “mandatory reporting laws leave little leeway for the individual clinician, causing harm to patient-clinician rapport, and preventing or excluding vulnerable patients from receiving the care they need, even when desired.”110Klie et al., “Integrated Care for Pregnant and Parenting People With Substance Use.” Although these rules stem from federal guidelines, the reality is that to meet federal standards, information on substance-exposed newborns must only be gathered for data collection.111See “Clearing the Path.” Oklahoma law forces further systems involvement, as the other chapter of this report, Clearing the Path, explains.
It is critical to understand that not all substance-exposed newborns experience immediate or perceptible health issues. Legal and child welfare involvement beyond assessing child safety is likely to cause more harm than good in these cases.112Lloyd, Luczak, and Lew, “Planning for Safe Care or Widening the Net?” The fraction of these infants who do experience withdrawal symptoms are diagnosed with Neonatal Abstinence Syndrome, or NAS.113Oklahoma Department of Human Services. “Substance Exposed Newborns State of Oklahoma 2021,” n.d. Infants exposed to substances in utero are far more likely to develop NAS if their mothers do not receive prenatal care and/or substance use treatment.114Klie, Kaylin A., Sarah Nagle-Yang, Lulu Zhao, and Melanie E. Fringuello. “Integrated Care for Pregnant and Parenting People With Substance Use.” Clinical Obstetrics & Gynecology 67, no. 1 (March 2024): 200–221. https://doi.org/10.1097/GRF.0000000000000831.
Stritzel, Haley. “Substance Use-Associated Infant Maltreatment Report Rates in the Context of Complex Prenatal Substance Use Policy Environments.” Child Maltreatment, November 13, 2023, 10775595231213404. https://doi.org/10.1177/10775595231213404.
Preliminary data from 2024 reveal that 780 infants tested positive for prenatal substance exposure in Oklahoma, and only 38 of those infants (4.87%) were diagnosed with NAS. In 2023, these figures were 823 and 56 (6.8%), respectively.
The 2021 spike in reports of substance-exposed newborns was likely driven by several factors, including language changes around reporting requirements,115This change is outlined in the legislative timeline included in Clearing the Path. pandemic-induced disruptions to healthcare access, the legalization of medical marijuana in 2018, and the chilling effect of a 2020 court ruling establishing that women with substance use disorder could be held criminally responsible for using drugs while pregnant.116See “Clearing the Path”
Despite Oklahoma’s emphasis on identifying and opening avenues for prosecuting women who use substances while pregnant, opportunities for families to receive care are lacking. When pregnant people don’t receive adequate services, the health of their children suffers as well. The 2023 Child Maltreatment report from the U.S. Department of Health & Human Services Administration for Children and Families Administration on Children and Youth and Families Children’s Bureau found that only 50.9% of infants born with prenatal substance exposure in Oklahoma received referral to appropriate services117A decrease from 51.0% in 2022 and 59.1% in 2021 U.S. Department of Health & Human Services Administration for Children and Families Administration on Children, Youth and Families Children’s Bureau, “Child Maltreatment 2023.” (i.e., foster care, early intervention services, mental/behavioral health treatment).
More recently, educational and awareness campaigns may have helped reduce the number of substance-exposed newborns in Oklahoma. Initiatives such as Tough As A Mother and Oklahoma State University’s Project ECHO, as well as organizations like the Oklahoma Perinatal Quality Improvement Collaborative, provide targeted messaging and education on prenatal substance use and best practices for providing care. However, when it comes to infant care, not all Oklahoma hospitals are created (or staffed) equally. Emma noted that “the best NICU for children that’s in Tulsa is also the most judgmental hospital. So if you have a child that’s going to go in NICU, because they are going into withdrawal, they’re going to send them to this hospital, but the nurses are going to treat [mom] like crap… It’s a catch-22.”
Emma’s evaluation of this NICU brings us back to the topic of stigma. While infants get great care at this hospital, parents face discrimination and judgment from staff, which may impact parental ability to bond and care for their infants.
Sophia experienced first-hand how frustrating and demoralizing it can be to have a poor relationship with NICU staff hinders the early development of a connection and sense of confidence in caring for her newborn. After being discharged from the hospital after her birth, she ran into communication difficulties with the NICU. Throughout her son’s stay, there would be times when Sophia was instructed to arrive at a certain time to spend time with her son, only to be kept from him or dismissed and told to wait… Only to be informed an hour later that it wouldn’t be possible to see him that day. She said:
“I understand that there [are systems] in place, so, like, somebody can’t run off with their child, or what have you, right? But there was a lot of confusion as to when I could be around my kid, when I could see him, when I could hold him, or feed him.”
These challenges made Sophia feel like her efforts to parent were not being acknowledged or respected. When looking back at how she was treated at that time, she said, “I was trying, you know. And my trying may not look like everybody else’s, but it would have been nice to try to bond with my newborn. I wasn’t given that opportunity until he was about five or six months old. That was really hard.” Sophia was not the only one to be harmed by that bond being disrupted. The parent/infant bond is important to infant development.118NICHQ. “Interrupting the Mother-Child Dyad Is Not the Answer to Infant Safety.” NICHQ – National Institute for Children’s Health Quality, February 20, 2019. https://nichq.org/insight/interrupting-mother-childdyad-not-answer-infant-safety. Experts on neonatal substance exposure also stress the importance of this relationship for improving infant health outcomes.119Center for Children and Family Futures, “Substance Exposed Infants: A Report on Progress in Practice and Policy Development in States Participating in A Program of In-Depth Technical Assistance September 2014 to September 2016.”
In addition to its benefit to infant health,120Ibid. 121Darlington et al., “Outcomes and Experiences after Child Custody Loss among Mothers Who Use Drugs.” 122Lloyd Sieger, “What Progressive Work Are Other States Doing?” 2024 mother/infant bonding was the greatest motivation for moms in our study to seek and stay in treatment. After being admitted to a prison diversion program, Emma said her first words to her new therapist were: “If you cannot guarantee that I will get to see my kid at the end of this, then you need to just send me to prison.” Emma did not see the point of treatment and recovery if it did not lead to reunification with her child.
Her sentiment is not uncommon. A 2023 study of mothers who had lost custody of children due to substance use found that “non-punitive leveraging of the maternal bond can bolster hope to support self-driven treatment engagement.” The non-punitive stipulation of this recommendation is critical. While separation from children can lead to a loss of hope and a feeling of resignation, as Emma expressed, the opportunity to continue parenting while receiving treatment instilled other participants with higher morale and more confidence in their ability to succeed.
Ellie revealed that the maternal bond with her son was the sole motivator for continuing to cooperate with her program.
“The only thing that honestly keeps me going is my four-month-old, because it’s not just me in this recovery program. It’s me and him. So every decision I make, every move I make, is focused on, like, can he come with me? Or if I do this, will it risk him staying with me? So he’s definitely my motivation.”
Ellie emphasized the idea that they were going through recovery together. This was true in the explicit sense that he was present, but more importantly, his presence shaped Ellie’s decision-making. She was guided to make the decisions that would be best for her recovery because those decisions would also impact whether her son would be allowed to stay with her. Thus, her desire to parent shaped the way she approached her role in her SUD program.
Because of health issues, Ivy was living with her parents and attending outpatient services at the time of her interview. In a typical situation, Ivy would have been allowed to room-in with only her youngest child while the other stayed with her parents (or was placed into foster care if they were unable or incapable of being the child’s guardians).
“I get to have [them] in the program right now… It’s kind of stressful to have a one-year-old and a two-month-old, but I’m doing it, and I like it. It’s a really amazing feeling to just have both for your kids and stuff like that and not just be around one of them. So I’m really just enjoying the time that I get to have with both of them.”
Although it was difficult, Ivy expressed the joy that she felt in being able to parent both of her young children while in her SUD program. Rather than being separated from her oldest, she was able to bond with them both and enjoy their time together during the crucial development period of their infancy.
Emma graduated from her SUD treatment program around the time she discovered she was pregnant for the second time. Because she was at a different place in her path to recovery, Emma saw the relationship with her secondborn not just as motivation for success, but as a representation of her ability to be a healthy parent and provider for her youngest child. Thinking about her own childhood and current relationships to family, she said, “My mom’s still in active addiction, my brother is still in active addiction… I’m kind of the first to break that generational curse and to seek treatment.” After SUD treatment, Emma had the tools she needed to accomplish her goal of being a healthy parent. She said, “It was important to me that youngest daughter [and I] be bonded and attached in a healthy way and [for her to] know that whenever she needs something that her mom is going to meet her needs.”
Active participation in SUD treatment was life-altering for participants who spoke with us. Treatment programs did not simply keep clients from using or threaten punitive measures for use. When appropriately educated on working with pregnant people with substance use disorder (PPWSUD), providers understand, as Bella told us, that “just because you have a substance use disorder and you’re pregnant, doesn’t mean that the substance use disorder stops.”
Oklahoma’s substance use treatment services had around 16,000-17,000 admissions per year from 2001-2009, with a steep decline in 2010 that continued until 2013. From 2009-2011, budget cuts at the state and federal levels reduced funding for substance use treatment services and led to ballooning waitlists for care.123Graham, “Funding Cuts Hamper Addiction Treatments,” State of Addiction, ODMHSAS, 2012. “State of Addiction,” a report put together by ODHMSAS in 2012, shows the agency faced 11% budget cuts between 2009 and the report’s publication, totaling $36.5 million in cuts at the state level alone. An additional 21% cut in state and federal appropriations to substance abuse programs coincided with the loss of 95 treatment beds across the state. In 2011, these cuts added 1,200 Oklahomans to the waitlist for treatment, joining the 1,000 already there. Admissions have not risen above the 2009 count in the years since.
In 2022, the most recent year for which we have data, there were more than 13,000 admissions to treatment in Oklahoma, but only 162 admissions of pregnant individuals.
Treatment programs provide services and resources such as therapy, group therapy, and medications for substance use disorder, alongside instruction in crucial life skills such as “how to be responsible, how to pay bills, how to budget, how to watch your credit, [and] how to dress for interviews,” as Emma noted about her prison diversion program.
Emma didn’t just gain life tools, either. She gained a support system. Emma spent her first pregnancy carrying around the “‘What to Expect When Expecting’ book like it was the bible,” because her mom was in active addiction, and she didn’t have female friends. Her pregnancy with her second child was different. Because of the new support system she had built, she knew more about being pregnant, and she had supportive relationships with women she could trust with her questions.
Emma’s description of her SUD treatment program shows how much it meant to her. She said,“ This is my safe place. As soon as I walked through those doors, it’s like, I know I’m safe. There’s no ulterior motives, every individual in here just wants me to be the best version of myself.”
Similarly, Ivy felt like being in treatment was the first time she had ever had people who were on her side to listen, no matter what. It gave her the opportunity to talk about things she had never talked about with anyone.
“I feel like I get to talk about things I’ve never been able to talk about. I feel like I have people that actually care about what I’m saying. And not just looking at me, thinking that they’re listening and just throwing me off. Like, they actually sit down and actually take the time in their day to actually listen to what I have to say and then give me feedback. So it’s pretty supportive, and I really do enjoy it. I got to talk about things that are not comfortable about talking about what nobody.”
As a care provider, Bella noted that this kind of support can begin to break away at the fear instilled in people who are used to punishment instead of compassion. She shared, “‘Let’s get a team wrapped around you [with] resources,’ and it kind of teaches them… instead of ‘Oh, my God, this came up, I have to hide. I have to run,’ they ask for help, and that’s just very positive.”
The path to recovery does not end after graduating from SUD treatment. As our participants shared, recovery is not about stopping your substance use. It is about continuous lifestyle changes that break intergenerational cycles of drug abuse, systems involvement, and poverty. These changes are far more likely to occur in supportive environments that prioritize mothers’ and babies’ safety and keeping families together. While the state of Oklahoma has some policy and medical and social service supports in place that do just that, there is ample – and critical – room for improvement.
As public health experts and addiction specialists have repeatedly stressed, “the triad of prenatal care, substance use treatment, and mental health treatment represent the common foundation of evidence-based models of integrated care for women with substance use disorders.”124Klie et al., “Integrated Care for Pregnant and Parenting People With Substance Use.” 2023 When states do not provide adequate access to this care triad, families suffer. The same is true when services exist but access is obstructed through policies that punish individuals for seeking it.
Experts at the intersection of criminal and reproductive justice assert that we should instead reject “mass incarceration and the use of the criminal justice system to address problems [which are] better addressed through adequate social services (especially mental health and substance abuse services).”125Law Students for Reproductive Justice and National Women’s Law Center, “If You Really Care about Criminal Justice, You Should Care about Reproductive Justice!” Our interviews spotlight several opportunities for lawmakers and treatment providers to create a more effective and compassionate statewide approach to care.126The second chapter of this report, Clearing the Path, dives deeper into Oklahoma’s legislative history of substance use criminalization and details our policy recommendations.
Without access to specialized information and treatment, parents struggle to find information to support themselves and their children. Moms in our study recalled wanting to change their substance use behaviors during pregnancy but lacked resources necessary to guide those decisions.
However, access to these programs is not spread equally across the state. While parents living in Tulsa and Oklahoma counties have programs in their area, those living in rural areas may find themselves facing sentencing disparities and no programmatic support for their very similar situations. Even if someone is able to be admitted into a prison diversion program, they may still find themselves separated from their infants if rooming-in is not permitted. In these cases, the valuable connection between mom and baby is disrupted, and opportunities for parental support to serve as a source of stability and motivation during recovery may be missed.
The current pattern of leaving parents to figure things out on their own is not sustainable.
Clearing the Path offers further insight and strategies for implementing these recommendations.
