Comprehensive Addiction in Pregnancy Clinic
A One-Stop, Relationship-Driven Model for Pregnant Women with Substance Use Disorder
The University of Alabama at Birmingham built a one-stop clinic where pregnant women with substance use disorder can see a maternal-fetal medicine physician, a licensed counselor, a case manager, and a peer recovery specialist in a single Tuesday visit, paired with on-site outpatient treatment, medication for opioid use disorder, and one year of postpartum follow-up, all designed to replace the fear of arrest with a safe pathway to prenatal care and recovery.
The Challenge They Were Addressing
In Alabama, using drugs during pregnancy can be prosecuted as chemical endangerment of a child. The law puts pregnant women with substance use disorder in an impossible bind. A positive drug screen at a prenatal visit could trigger an arrest. Women in many parts of the state, including rural areas where prenatal care was already scarce, were quietly hiding their pregnancies until delivery out of fear of incarceration, and in some cases out of fear that a miscarriage after a jail detox would be charged as murder. Alabama's fetal and neonatal outcomes reflected that fear.
The UAB Division of Maternal-Fetal Medicine already operated a Complications Clinic for higher-risk pregnancies. Substance use was one of those complications, but there was no coordinated treatment pathway inside the clinic, no on-site counseling, no peer support, no warm hand-off to residential treatment, and no medication access at the point of prenatal care. Women who did show up were scattered across services, appointment days, and agencies that did not always talk to each other.
CAPP was built to replace that fragmentation with a single door. The program launched in 2018 under a federal Regional Partnership Grant, a research study designed to test whether putting prenatal care, substance use treatment, case management, and peer support in the same room on the same day would improve outcomes for mothers and babies. When the Regional Partnership Grant ended, the clinic and physicians remained (billing insurance and Medicaid for their services), but the wrap-around team had to be cut back. Opioid settlement funding, beginning in 2024, allowed UAB to rebuild the full team, add on-site outpatient treatment, and extend follow-up a full year postpartum, the period when relapse is most likely for new mothers in early recovery.
What They Built
CAPP is a nook inside the UAB OB Complications Clinic. Every Tuesday, the CAPP team stands up a one-stop visit. A patient arrives and sees, in a single morning, an OB-GYN trained in high-risk pregnancies and medications for opioid use disorder (buprenorphine), a medical social worker, a case manager, and a peer recovery specialist. Group prenatal care spaces allow for group learning and guided discussions alongside peers who understand what they are going through. Individual medical care and prenatal exams are completed in private clinic rooms between meetings with the group and ancillary staff. Specialized prenatal education for patients with SUD is covered throughout pregnancy. It includes guidance on managing pain and pain medications in labor or post-surgery, awareness of postpartum depression signs and symptoms, working through postpartum physical and emotional changes as it relates specifically to SUD, and even working through the family court system.
On-site outpatient treatment is delivered at ASAM level 1.0. The clinical team uses a Stephanie Covington trauma-based treatment curriculum for women, chosen because so many patients are carrying prior trauma alongside substance use. For women who need a higher level of care, CAPP is a bridge: motivating hesitant patients toward residential treatment before they disengage, and providing a structured step-down for women finishing residential programs. The on-site physician provides buprenorphine (Subutex or Suboxone) for appropriate candidates and any other needed medical management.
A peer recovery specialist is central to the model. She has lived experience of substance use, incarceration, and child welfare involvement, including the termination of parental rights for one of her own children. She runs peer groups, visits patients in treatment, shows up at the hospital when patients deliver, and normalizes the hardest conversations in the room. When a woman feels there is no hope, the peer is the one who can truthfully say that recovery is possible.
CAPP pulls in women from wherever they are. Local residential treatment facilities, including Aletheia House and Olivia's House, transport pregnant clients to and from the clinic on Tuesdays, as well as to pharmacies or other needed medical appointments. CAPP receives internal referrals from other UAB OBGYN clinics, including the OB Complications Clinic, as well as from health departments across Jefferson County. CAPP also receives referrals from across the state, including rural and suburban OB-GYN offices, when they encounter substance use in prenatal care. Emergency departments, family and drug courts, jails, and the Alabama Department of Human Resources all know where to send pregnant women who need this combination of services. The Alabama Department of Mental Health calls when a woman from anywhere in the state reaches out for help.
The model travels. When DMH asked UAB for help establishing a version of CAPP in rural Walker County, where the county had the highest overdose rate in the state and some of the highest rates of babies born with prenatal substance exposure, the UAB team spent two years on the ground. They worked with the local doctor's office that provided prenatal care, supported their clinicians in obtaining X-waivers (a former requirement for prescribing buprenorphine), and partnered with an existing local treatment provider to launch a women-specific group that meets at the doctor's office on Fridays. The local program, called She Recovers, now runs independently of UAB.
Key Program Components
Who You Need at the Table
What made a willing partner essential vs. optional?
The difference between a required and a helpful partner is whether the Tuesday visit can happen without them. Required partners sit inside the clinical and care-coordination core: the OB practice that delivers prenatal care and prescribes medication, the treatment team that delivers the on-site substance use groups or coordinates off-site treatment, the peer who holds the relational center, the child welfare office that is responsible for a coordinated Plan of Safe Care, and the family court that makes final decisions on safe infant disposition. Remove any one of these, and the one-stop design collapses back into the fragmented system the program was built to replace.
Helpful partners expand reach and sustainability without being essential to day-one operations. The state mental health department made rural replication possible. UAB Hospital's delivery staff reinforces the clinical culture that the program is trying to build. Alabama's Medicaid program covers clinical visits and medications for a significant portion of CAPP participants, expanding access to care for patients with financial limitations and supporting essential clinical operations by reimbursing prenatal services. Each adds durability, but none of them replaces the core Tuesday team.
Across all of these partnerships, the common ingredient is relational trust built over time. The team spent years building this foundation of the program; answering late calls from residential facilities and emergency departments, following patients through hospital admissions and court dates, and showing up at doctors' offices with lunch and donuts. Initial visits with patients often take one to two hours, as building rapport with patients who frequently suspect medical establishments of having ulterior motives is essential. These relationships are what allowed for a single Tuesday visit for a patient to become coordinated care across systems that usually do not coordinate at all.
Budget Breakdown
What is the minimum viable budget to replicate this?
A county does not need a new clinic to replicate this model. The rural Walker County version (She Recovers) runs on roughly $75,000 to $150,000 per year by partnering with an existing OB practice, supporting those physicians in obtaining adequate training to prescribe buprenorphine, and co-locating a women-specific treatment group with an existing local treatment provider. The floor is staffed by one dedicated staff member who maintains relationships across the OB office, the treatment provider, child welfare, and the courts; a peer recovery specialist with lived experience; and a modest budget for transportation, medication vouchers, and incentives. The significant investment is relational, not financial.
What Worked and Why
Specific decisions or design features that drove success
Putting prenatal care, medication, treatment, case management, and peer support inside a single Tuesday visit was the design choice that reshaped engagement. A pregnant woman in active use often lacks the capacity to coordinate four separate appointments across three agencies. Collapsing those touchpoints into one morning, in one building, and with a team experienced in trauma-informed, nonjudgmental communication around substance use in pregnancy, removed the logistical and relational barriers that have long caused patients to drop out between referral and first visit.
Organizing prenatal care in a group setting with peers has created a unique communal space that helps normalize the experience and support connection among participants. Patients sit with other pregnant women, talking about the same physical changes, the same fears, the same milestones. Substance use challenges and education are discussed, but this is alongside topics on pregnancy, postpartum, and parenting. Patients describe the CAPP group as the first place they were treated like pregnant women, and people with a diagnosis second.
Hiring a peer recovery specialist with deep lived experience, including the loss of a child to child welfare, gave the program something clinicians alone cannot provide. The peer sits in groups, visits patients in residential treatment and at the hospital, rides along to court hearings, and translates between the patient's experience and the clinical team's plan. Patients tell her things they will not tell a doctor. Clinicians hear things through her that they would otherwise miss.
Framing the work around infant outcomes kept the program funded across changes in state leadership. Alabama's policy climate is not uniformly supportive of treatment for substance use disorder, and elements of the field that thrive in other states do not operate here. The program works through that reality by anchoring the public story in the health of unborn and newborn babies, a value that cuts across political lines. That framing preserves space for evidence-based clinical work to continue by focusing on the important outcomes valued by the community, regardless of political affiliation.
Building the Plan of Safe Care folder as a portable, patient-held document prevented a recurring failure mode at delivery. Without it, a pregnant woman in recovery could arrive at labor and delivery and be treated as a liability instead of a patient: drug-tested, surveilled, and separated from her baby through process rather than clinical judgment. The folder carries the summary of the patient's CAPP participation, treatment, and parenting class certificates if completed, the proposed discharge plan, and the clinical team's contact information directly into the delivery room, so the hospital staff and the child welfare worker start from the same page that the CAPP team has been writing all along.
Early outcomes and data
Outcomes being tracked as part of the OSF grant funding:
Proportion of infants born without non-prescribed substances in their system is the primary clinical outcome the program tracks.
Proportion of CAPP mothers going home with their babies after delivery, rather than being separated at the hospital, is the second core outcome.
Dose of prenatal care delivered (total prenatal visits completed). This was shown to be higher for CAPP patients than for pregnant women with substance use disorder who were not engaged in the program, consistent with findings from the original 2018 research study.
Treatment completion and treatment retention through delivery and into the first postpartum year.
Buprenorphine adherence for those prescribed.
Other contributions:
A CAPP-produced stigma video is now part of the required training for all physicians at UAB Hospital.
The model has been successfully replicated in rural Walker County as She Recovers, which now runs independently of UAB.
Outcome reporting framework now extends through one year postpartum, made possible by opioid settlement funding.
Lessons Learned
Be adaptable. The program has survived shifts in funding, politics, leadership, and the clinical profile of the women walking in the door. The team does not fight the environment; they design around it. That mindset, more than any single program element, is what has kept CAPP running since 2018 and what allowed the model to travel to rural Walker County.
Build the relationships before you build the program. The most important year of CAPP's life was probably the one spent walking into doctors' offices with lunch, introducing staff at treatment facilities, and sitting in family court. Every partnership the program now depends on was born in those conversations. Schedule that time early.
Hire the peer first, or as close to first as possible. A peer recovery specialist with deep lived experience is the single most important hire and usually the hardest to make. Start recruiting before you need to fill the position. Protect the role from being absorbed into case management or administrative work; the peer's value is in relational depth.
Design for the patients you actually see. Planning assumptions about acuity, stage of pregnancy, insurance status, and child welfare involvement will almost always be optimistic. Revisit them every six months and adjust staffing, clinical capacity, and partner agreements accordingly.
Frame the work around shared values. In any political climate, there is a framing that opens doors and one that closes them. For CAPP, that framing is the health of unborn and newborn babies. The internal work, medication, trauma-based treatment, and peer support continue unchanged; the public story leads with the outcome the whole community agrees on.