A new study from Oregon Health & Science University shows that a team-based, whole-person approach to caring for pregnant people with substance use disorders holds promise in improving health outcomes and helping keep families together.
The findings come from an in-depth look at seven organizations participating in Project Nurture and its rural expansion, Nurture Oregon — models designed to deliver integrated, stigma-free care by bringing together medical, behavioral health and social support professionals. The results were published Monday in the Annals of Family Medicine.
This care model comes at a critical time. In 2020, between 8% and 11% of pregnant women reported using illicit drugs, alcohol or tobacco — likely an underestimate due to self-reporting. Substance use during pregnancy is linked to serious health risks for both parent and infant, including preterm birth, extended hospital stays and increased involvement with child welfare systems. Yet only 1 in 10 pregnant people with substance abuse disorders receives treatment, often due to cost, stigma and lack of access — especially in rural areas.
For Deborah Cohen, Ph.D., professor of family medicine in the OHSU School of Medicine and lead author of the study, the power of this care model became especially clear during a visit to a Project Nurture site.
"I was sitting next to a young woman who had just had a baby; she was about the same age as my daughter," Cohen said. "And I realized we talk so much about what's good for the infant, but we're changing the lives of two people. This young woman was in recovery, reconnecting with her family, taking care of her child and looking at college. That's what this kind of care does — it changes lives."
Challenges in expanding the model
Researchers identified 14 key care team functions, grouped into five categories: medical care, behavioral health, coordination and resources, patient support and engagement and leadership for quality improvement. Teams typically included family physicians, certified nurse midwives, social workers, addiction counselors, peer support professionals and doulas.
"Many of these functions, such as outreach, coordination and advocacy, are invisible but essential," Cohen said. "Because this work is often unpaid or unrecognized in fee-for-service systems, it can be easy to overlook. But it's exactly the kind of work that helps people stay engaged in care."
The expansion of Project Nurture into rural communities through Nurture Oregon faced new challenges. While original sites had strong medical partnerships, many of the new behavioral health and substance use treatment organizations struggled to fully integrate medical care into their teams.
"Some of the behavioral health organizations found it hard to establish medical partnerships," Cohen said. "They relied more heavily on peers and doulas to support patients and help them navigate medical care elsewhere. It's a creative workaround, but it's not the same as having fully integrated care in one place."
In the study, organizations that included family physicians were better able to deliver the full range of medical services, highlighting the importance of training and supporting full-scope primary care clinicians.
Still, all teams delivered essential services like care coordination, emotional support and help with social needs. These efforts made a difference in patients' lives.
Policy implications
The study also highlights systemic issues. Cohen emphasized that while integrated, whole-person care saves lives and strengthens families, it's hard to sustain under current payment models.
"There's a lot of unpaid work that primary care doctors and care teams take on —connecting the dots, coordinating care and showing up for patients," she said. "The return on investment of good primary care isn't to the health care system — it's to the community. And that makes it hard to fund unless policymakers and payers are visionary and willing to invest with a long-term view."
Cohen hopes the findings will serve as a guide for what interdisciplinary care should look like, not just for people with substance abuse disorders during pregnancy, but as a model for primary care more broadly.
"People need to know what to expect from a good care team," she said. "And payers and policymakers need to know what to pay for. This study shows what that can and should look like, especially for people who have the most to gain from compassionate, coordinated care."
In addition to Cohen, OHSU co-authors include: Jennifer D. Hall, M.P.H., Maria Danna, M.A.; as well as Camille C. Cioffi, Ph.D., with the Oregon Research Institute; Helen Bellanca, M.D., M.P.H., with Kaiser Permanente; and Andrea Baron, M.P.H., and Viviane Cahen, M.D.
This study was funded by a grant from the National Institutes of Child Health and Human Development, of the National Institutes of Health, under award number R01HD105348. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or other funders.
