Substance Use in Pregnancy: What's Behind the Numbers

A trauma-informed, non-judgmental look at why this happens, what it means, and

what actually helps.

What You're Not Seeing in That Neighborhood

Drive through certain parts of coastal New England and the picture looks prosperous. Large houses set back from the water, restaurants full on summer weekends, the kind of scenery that reads as comfortable and established.

What that picture doesn't show is what happens in October. When the seasonal restaurants close, the summer rentals empty, and the people who kept all of it running — the line cooks, the housekeepers, the landscapers, the dock workers — are left with irregular income, no employer-sponsored insurance, and a cost of living that was set by the summer crowd.

This is the reality in places like Cape Cod and Newport County: two economies sharing the same zip codes. One seasonal and wealthy. One year-round and scraping by. And that economic reality — the chronic stress of it, the instability, the isolation of off-season — has direct, documented effects on health. Including on the health of pregnant families.

Substance Use in Pregnancy Isn't a Character Flaw. It's a Health Issue with Deep Roots.

Before anything else: substance use during pregnancy is a health issue, not a moral failing. The American Society of Addiction Medicine classified addiction as a chronic brain disorder in 2011 — not a behavior problem or the result of making bad choices. That framing matters, because the way we understand the cause shapes the kind of help we offer.

And what the research tells us, clearly and consistently, is that the roots of substance use during pregnancy run deeper than any individual's choices. They run through childhood. Through economics. Through trauma that was never treated because treatment was never available.

The ACEs Connection

Adverse Childhood Experiences — what researchers call ACEs — are events in childhood that create lasting impacts on health: abuse, neglect, household dysfunction, parental incarceration, domestic violence, loss of a parent. The original CDC-Kaiser Permanente ACEs study is one of the most influential public health studies ever conducted, and it showed that ACEs don't stay in childhood. They follow people into adulthood and pregnancy.

Pregnant people who have experienced ACEs — especially those with four or more — are at meaningful risk for prenatal substance use. In one study of mothers referred to a hospital's child protection team, over half had four or more ACEs, compared to about 15% of women in the general population. PubMed Central

The pathway isn't direct — it runs through other things first. Research shows that the association between ACEs and substance use in pregnancy is mediated by education level, depression, and previous history of substance use — meaning that childhood adversity leads to socioeconomic and mental health challenges, which then increase the risk for substance use during pregnancy. PubMed

In other words: the story of a pregnant person using substances is rarely just about the pregnancy. It's usually a chapter in a much longer story that started decades earlier, in a household where no one was safe or stable.

ACEs are also associated with higher odds of anxiety and depressive disorders, depressive symptoms, and intimate partner violence during pregnancy — and the risk is greatest for people with low resilience, which is itself often a product of having too few protective relationships and resources growing up. MDPI

The Inequality Layer

Here's where the economic piece enters.

Research on rural and coastal high-amenity communities — places shaped by seasonal tourism economies — has found that long-term residents struggle with increases in the cost of living as wealthier people move in, and that employment in these communities is concentrated in low-paying seasonal and part-time service work. PubMed Central That's not an abstract finding. That's a description of what happens every year in communities up and down the New England coast.

Chronic economic stress — housing instability, food insecurity, unpredictable income, the threat of losing everything in an off-season — activates the same stress response systems that ACEs activate. When the body's stress response is chronically overloaded and there's no access to mental health care, no paid leave, no safety net — substances can become a way of managing something that feels unmanageable.

Rural and economically marginalized women are specifically challenged in accessing rehabilitation care, and they often experience additional stigma in smaller, more insular communities Rural Health Information Hub — communities where everyone knows everyone, and getting help means being seen.

That stigma keeps people quiet. And quiet, in this context, means untreated.

The Fear That Keeps People From Getting Help

One of the most significant barriers to care for pregnant people using substances is fear. Fear of losing their baby. Fear of involvement from child protective services. Fear of being judged by a provider who was supposed to be safe.

That fear is not unfounded — it's shaped by real experience, and by a healthcare and legal system that has sometimes punished people for being honest about their struggles. Criminalization of substance use during pregnancy varies by state and has been documented to drive people away from prenatal care entirely, which makes outcomes for both parent and baby worse.

This is why trauma-informed, non-punitive care isn't just a nice idea — it's a clinical and public health necessity. Routine prenatal ACEs screening and universal, non-punitive approaches to substance use may provide opportunities for intervention while reducing the transgenerational impact of ACEs. PubMed Central When people feel safe telling the truth, they can actually get help.

Know Your State — And Act Accordingly

Trauma-informed care doesn't exist in a vacuum. It exists inside a legal and policy landscape that varies dramatically depending on where you live — and birth workers who don't know that landscape can inadvertently cause serious harm, even with the best intentions.

Some states treat substance use during pregnancy as a public health issue. Others treat it as a crime. As of 2025, at least 25 states and the District of Columbia have laws that specifically address substance use during pregnancy — some requiring treatment referrals, others mandating reporting to child protective services, and some classifying use as child abuse or grounds for civil commitment. Tennessee was the first state to criminally prosecute pregnant people for drug use under a fetal assault law. Alabama has used chemical endangerment statutes to prosecute. The list grows.

This matters for birth workers because your role puts you in direct contact with people who may be sharing things with you that they aren't sharing with anyone else. Understanding what mandatory reporting requirements apply to you — and to the providers in your client's care team — is not optional. It's part of your scope.

A few things to know and do:

Know whether doulas are mandatory reporters in your state. 

In most states, doulas are not mandated reporters. But the providers your clients are also seeing — OBs, midwives, nurses — may be. Understanding that landscape helps you prepare your client for what disclosure to their medical team might mean, so they can make an informed decision about what to share and with whom.

Know your state's specific laws around substance use in pregnancy. 

The National Advocates for Pregnant Women (NAPW) maintains updated resources on state-by-state criminalization. If you're practicing in a punitive state, you need to know what your clients are walking into when they're honest with a provider.

Know the difference between supporting and surveilling. 

Your job is to support your client — not to report on them. In states where disclosure carries real legal risk, connecting a client with harm reduction resources, non-punitive treatment programs, and legal advocacy organizations may be more protective than encouraging full transparency with a healthcare provider who is a mandated reporter.

Know your local resources cold. 

Which treatment programs in your area are pregnant-and-parenting-friendly? Which won't require surrendering custody to get help? Which providers are known to be non-punitive? That knowledge is part of your toolkit — and in some communities, it's lifesaving.

The goal is always the same: keep the parent and baby safer. But how you get there depends on where you are. A birth worker in Vermont is operating in a fundamentally different legal environment than one in Alabama — and pretending otherwise doesn't protect anyone.

What Trauma-Informed Care Actually Looks Like

For families, trauma-informed care means providers who ask about your history without using it against you. Who understand that using during pregnancy is often a symptom of something much older, not evidence that you don't love your baby. Who offer support without surveillance.

For doulas and birth workers, it means:

• Knowing your client's history doesn't mean knowing their whole story — ask open questions and listen without an agenda.

• Understand that a person who has a history of trauma may respond to medical settings, authority figures, and interventions in ways that look like "non-compliance" but are actually self-protection.

• Know that shame closes people down, and that practical, non-judgmental support opens them back up.

• Be familiar with the resources in your area so that when a family trusts you enough to be honest, you have something real to offer them.

If You Need Support — or Know Someone Who Does

Getting help during pregnancy is possible, and there are people whose entire job is to make it less scary.

Nationally: SAMHSA National Helpline — free, confidential, 24/7: 1-800-662-4357

In Rhode Island: RIDOH's Perinatal Substance Use Program focuses on care coordination, access to bias-free prenatal care and treatment, and protection of the parent-child relationship. Department of Health The state also runs the "Pregnant? Using? We Can Help" campaign specifically to reduce stigma around asking for help. RI Buprenorphine Hotline (24/7): 401-606-5456

RI MomsPRN — free psychiatric consultation and referral for perinatal mental health and substance use: (401) 430-2800

In Massachusetts: The Women and Family Referral Center provides information, warm referrals, and support for anyone with questions about substance use, and can help pregnant people develop a Family Care Plan. Pregnant people in need of residential services are prioritized for the next available bed. Mass.gov Phone: (866) 705-2807

Massachusetts Substance Use Helpline — free, 24/7: (800) 327-5050

The Bottom Line

Substance use during pregnancy happens in big houses and small apartments. In communities that look fine from the outside and aren't. In people who had impossible childhoods and never got the help they needed. In people who are doing the best they can with what they have.

Judgment has never helped a baby. Support has.

If you're a birth worker: your non-judgmental presence matters more than you know. You may be the first person in a client's life who has treated their whole story with care.

If you're a pregnant person who is struggling: you are not alone, you are not a bad parent for needing help, and there are people who want to support you — not punish you — for asking.

Sources: PMC — The Effect of Maternal ACEs on Substance Use During Pregnancy (Duka et al., 2023); PMC — Pathways from Maternal ACEs to Substance Use in Pregnancy; PMC — Associations Between ACEs and Prenatal Mental Health and Substance Use (Kaiser Permanente, 2023); PMC — Population Change and Income Inequality in Rural America; Rural Health Information Hub — Rural Maternal Health; RI RIDOH Perinatal Substance Use Program; Mass.gov Substance Use Resources for Pregnant and Parenting Individuals; National Advocates for Pregnant Women (NAPW)