For years, Shari Cook came across pregnant patients who struggled with substance use and wanted to get sober before their babies arrived. Finding somewhere they could actually get that treatment was another matter.
Some programs would accept women, but not if they were pregnant. Others had availability, but they were hours away and required women to leave their families to get treatment — another barrier that kept them from getting the care they needed as they were preparing to become a parent. Cook, a family nurse practitioner at Missouri Ozarks Community Health in Ava, Missouri, ultimately had few options for referring one of her patients to treatment.
Missouri saw nearly 1,500 drug-related deaths in 2024, data from the state Department of Mental Health show, and rural Missourians can face additional hurdles to getting specialized treatment.
For pregnant women, seeking treatment can mean navigating addiction and prenatal care at the same time while also confronting fears about disclosing substance use, potential legal involvement and how getting treatment might impact their families.
But as more addiction treatment centers come online in Missouri, creating a safe enough environment for women to be honest about their substance use is another challenge providers must take on, said Lori Epley, who runs program outreach at Chestnut Health Systems in Hillsboro, Missouri.
“I think the barrier is really trying to figure out who the women are,” Epley said. “Because I think they’re very scared and fearful to disclose that information to anyone, because there could be potential consequences with their children.”
Recently, Missouri Ozarks Community Health opened their own treatment program. Now, Cook can connect patients directly with substance use counselors through Missouri Ozarks, the same place they’re getting their pregnancy care.
It’s one example of how Missouri is working to close the gaps in addiction treatment for pregnant and postpartum women — and hopefully save lives.
Missouri’s Pregnancy-Associated Mortality Review Board found that seven of the 108 pregnancy-related deaths from 2019 to 2023 were attributed to substance use disorder. All of the deaths associated with substance use were considered preventable.
The state review board considers whether doctors or nurses missed opportunities to identify substance use or connect their pregnant and postpartum patients with treatment, said Dr. Kimberly Brandt, the board’s chair.
As the state looks to improve maternal outcomes, it’s investing in programs that combine obstetric, psychiatric and addiction treatment. Using telehealth services, peer support specialists and expanding access to specialized providers are all part of the puzzle Missouri is trying to solve.
But organizations behind those efforts say addressing those deaths isn’t just a question of whether a treatment center exists. Many women need help with things like transportation to treatment, housing support, childcare, psychiatric treatment and help navigating it all.
Treating substance use during pregnancy requires more than medical care
Pregnancy can create an opportunity to connect women with treatment for substance use disorders that may have existed long before they became pregnant. Regular prenatal appointments and Missouri’s extension of Medicaid coverage through the first year postpartum give providers more time to establish those treatment plans.
“You don’t have to be pregnant to have a substance use disorder, but when you have it, we know that we have a higher capture rate of that person’s attention,” said Alison Williams, who runs the Missouri Perinatal Quality Collaborative. “So we have about two years with this individual where we can reach in and try to make a difference.”
Still, figuring out the care that someone navigating both a pregnancy and addiction may need isn’t always straightforward.
For opioid use disorder, medications such as methadone or buprenorphine are recommended during pregnancy. But women may also need psychiatric treatment for other mental health conditions, counseling, support from those who’ve been through treatment and other continued medical care.
Experts agree pregnancy is a time where those services can work best together, rather than treating a substance use disorder and a pregnancy as separate conditions.
For Dr. Traci Johnson, a maternal-fetal medicine specialist at University Health in Kansas City, some of the most concerning cases she’s reviewed as a member of the mortality review board involved women who were already receiving medical care when they died.
Johnson said the board has reviewed deaths of patients whose substance use wasn’t appropriately identified, as well as cases in which changes to medications contributed to a series of events ending in an overdose.
“We see things like people having opioid use disorder, they are in care, receiving care and have medications on board for opioid use disorder, and because of a lack of understanding in how to care for the population, clinicians will mess around with their medications, which sets off a constellation of events,” Johnson said. “And then it ends in overdose.”
Those cases demonstrate why Missouri’s new programs are trying to bring addiction, psychiatric and pregnancy care into one, rather than expecting patients and providers to figure them out separately.
That’s what Johnson is aiming to do with a new initiative she helped design at University Health. The EMBER program, Empowering Motherhood through Behavioral Health, Education and Recovery, launched in August 2025, brings doctors who work with moms and new babies into an addiction and psychiatric treatment setting.
For example, the program has ultrasound services in the same building as addiction and psychiatric care to help reduce travel needed to appointments.
The goal is to make ongoing addiction and mental health care central to a mom’s treatment, even after delivery.
When a patient enters EMBER, staffers assess more than substance use and pregnancy-related medical needs. They ask about housing, food insecurity, transportation, intimate partner violence and legal concerns. Johnson estimates that about 80% of patients in the program don’t have consistent access to transportation.
“Someone will literally come pick them up and bring them to their appointments,” Johnson said.
Across the state in St. Louis, Brandt is taking a similar all-in-one approach with the BRAVE program, Building, Recovery, Advocacy, Validation and Empowerment. The program uses telehealth to connect pregnant and postpartum women with specialized addiction, psychiatric and obstetric care.
By leaning on telehealth services, Brandt said, treatment becomes more accessible for those who may struggle with transportation, childcare or getting time off work.
“Both programs are using telehealth,” Brandt said of BRAVE and EMBER. “We are able to potentially connect with patients in rural areas who wouldn’t otherwise maybe even have a psychiatrist in their county.”
Missouri is trying to connect the dots for substance use treatment for moms
Williams said the problem in more rural parts of the state isn’t always a complete lack of treatment. Sometimes, she said, people simply don’t know what is available to them.
She recalled working with a small hospital that didn’t know that a recovery center was located across the street.
“It’s even those types of things,” Williams said. “Like I think looking around instead of just giving the pat answer of, ‘Well, we don’t have any resources because we’re rural.’ It’s doing a little bit of digging.”
The Perinatal Quality Collaborative is trying to address some of those gaps through Project STORK, a pilot launched earlier this year to connect pregnant and postpartum women with certified peer recovery specialists who have additional training in maternal health.
Peer specialists draw on their own experiences with substance use and recovery to help other patients navigate treatment and services.
Williams said peers can build relationships with patients who may be reluctant to discuss substance use with other medical providers.
“You connect with someone who’s been in your shoes,” Williams said. “You can build trust with them.”
Williams’ team will be watching to see if having a peer increases the likelihood of getting into treatment and how long they stay sober.
Williams said the pilot, which is working with Chestnut Health Systems, Compass Health and Centerstone, could help establish whether Medicaid should reimburse additional peer recovery services for pregnant and postpartum women.
So far, Chestnut Health is still building out its pilot in Jefferson County, said program director Lori Epley. They’re working with WIC, Head Start, Children’s Division and other community partners to get referrals up and running, and hope to establish a strong relationship with Mercy Hospital’s obstetrics department in the county.
Chestnut’s peer support specialist works with other patients receiving substance use treatment, providing services ranging from transportation assistance and home visits, to help with employment and Medicaid applications.
Epley said Chestnut can bill Missouri for some of the peer recovery services, but certain case management activities aren’t reimbursable.
In Ava, Cook said having substance use treatment available locally has made it easier to connect pregnant patients with treatment. But even with local options, patients can struggle to make it to appointments, arrange transportation and navigate all the resources available to them.
Even when Medicaid covers transportation, Cook said, patients have reported rides that never arrived or missed appointments because they hadn’t been scheduled far enough in advance.
And while Cook can refer patients to treatment, she doesn’t always know whether they received that care until they’re back for the next prenatal appointment.
For many of the women Johnson treats, they’re facing a stack of overlapping challenges at the same time — addition, mental health conditions, unstable housing, lacking access to medical care — which make solving any of them even harder.
But the payoff is well worth it. She reminds herself that helping a mother recover can also change the trajectory of her children’s lives.
“It’s the hardest but the absolute most rewarding,” Johnson said. “The return on investment..I feel like it’s a hundredfold because when you can affect a mom in a positive way, it’ll change generations so exponentially when they become healthy.”
