Barriers to opioid replacement therapy in pregnant women with opioid use disorder: a systematic review

Abstract

BACKGROUND: Opioid use disorder (OUD) during pregnancy has increased dramatically, paralleling epidemic trends in the general population. Pregnant women with OUD face considerable risks of adverse outcomes. While medications for opioid use disorder (MOUD) is the mainstay of treatment, substantial barriers limit its implementation. Despite the critical need for effective interventions, a comprehensive synthesis of the challenges to MOUD during pregnancy remains lacking. This review examines these barriers to improve treatment access and outcomes for this vulnerable population. METHODS: This review was conducted in accordance with the PRISMA 2020 guidelines and was registered in PROSPERO (registration number: CRD420251047657). We searched for peer-reviewed articles in PubMed, Scopus, and ScienceDirect published between 2015 and 2025, using a combination of keywords and MeSH terms. Two independent reviewers screened studies, extracted data, and assessed quality using the Joanna Briggs Institute (JBI) critical appraisal tools. Discrepancies were resolved through consensus with a third author. Data were synthesized narratively to identify key challenges in the treatment of OUD during pregnancy. RESULTS: Of the 9,288 articles identified from databases and websites, 23 met the eligibility criteria, including 14 qualitative studies, 5 cross-sectional studies, and 4 review articles. Patient-related barriers to accessing MOUD for pregnant women with OUD included fear of stigma and child custody loss, concerns about fetal risks, childcare and legal issues, coping with abuse, guilt, social pressure, and financial constraints. Meanwhile, provider-related barriers involved knowledge gaps, inadequate training, bias, stigma, time constraints, and the perceived complexity of treating OUD during pregnancy. Moreover, system-level barriers such as fragmented care models, geographic disparities, gaps in insurance coverage, and punitive policies further limited access to treatment. CONCLUSION: Pregnant women with OUD face barriers including stigma, childcare demands, provider bias, training gaps, fragmented care, financial and insurance issues, and punitive policies. Implementing patient-centered care, provider education, policy reforms, and practical supports may help promote compassionate, equitable treatment for this vulnerable population.