Substance use and use disorder in pregnancy and postpartum

The intersection of reproductive and behavioural health is littered with misperceptions, judgements, and particularly cruel ignorance. ‘Why would someone who uses drugs want to be pregnant?’, ‘Don’t they know they are harming the baby?’ Statements like these are common, even among health care providers and reflect older and troubling narratives of deserving versus undeserving motherhood.

Reproductive control was the fuel and fodder that fed the twin engines of settler colonialism (Theobald, 2019) and slavery (Bridgewater, 2006) in the early centuries of the United States. Today, the human right to parent remains far from universal: forced child removals happen not only at our borders but also from the Family Regulation System (also known as child welfare or child protective services [sic]), access to contraception and abortion is markedly inequitable, and almost a third of women experience gender-based violence and many more are subject to reproductive coercion.

Contemporary debates over the legal status of the foetus, though primarily framed in the context of the regulation or criminalization of abortion, directly impact approaches to substance use in pregnancy. The elevation of foetal rights often comes at the expense of maternal autonomy and personhood and can create the perception (from healthcare, law, and the public at large) of maternal–foetal conflict. Drug use in pregnancy is often reflexively understood as an example of such conflict and justification for intervention (through incarceration in pregnancy or family separation following birth). Policies controlling reproduction and policies controlling drugs are indeed two sides of the same coin – both are rooted in bigotry and discrimination (Paltrow, 2002). This is why and how pregnant people who use drugs often find their parental fitness challenged, especially if they are poor, Black, or American Indian.

This special issue is a response to the false and destructive narratives that are common in considerations of substance use in pregnancy. The authors, experts in addiction science, public health, clinical care, public policy, and the law, all approach their topics as humanists with an eye towards justice. Each paper explores a facet of care – be it a particular substance, co-occurrence, timing, or consequence of care. Taken together these papers resist the false dichotomy of obstetric conflict and illustrate healthcare that is person-centred, family-centred, evidence-based, and equitable. In addition, these papers break out of ‘the pregnancy box’ and place pregnancy in the life course that highlights the unique structural vulnerabilities that emerge especially postpartum. It is hoped that these papers will support providers and encourage research and public health to keep the lives and experiences of pregnant and parenting who use drugs centred in their work.