Growing recognition of gender-specific disparities in mental health has led to increased attention and investment in behavioural health services for women, including care for substance use disorders (SUD). As these efforts expand, obstetrician-gynaecologists (OB/GYNs)—who provide care to two-thirds of women in the USA annually—are uniquely positioned to integrate behavioural health services into routine visits.1 For one in five women, their OB/GYN serves as their main point of contact within the healthcare system.2 These longitudinal relationships and regularity of visits across the life course create a critical and often underutilised opportunity: embedding substance use screening and interventions into OB/GYN care.
Emerging evidence highlights the intersection between reproductive health and substance use behaviours. In a recent study, approximately half of patients in an inpatient substance use treatment facility reported using substances—including cannabis, alcohol and nicotine/tobacco—to manage their menstrual pain.3 Other studies show that women with endometriosis are at increased risk for chronic opioid use and overdose,4 and similar patterns have been documented across other chronic pain conditions disproportionately affecting women, such as migraines, rheumatoid arthritis and interstitial cystitis.5
One commonly adopted model for integrating behavioural health interventions into medical settings is SBIRT: Screening, Brief Intervention, and Referral to Treatment. In women’s healthcare, SBIRT for substance use has largely been confined to pregnancy. For instance, the American College of Obstetricians and Gynecologists recommends substance use screening at the first prenatal visit,6 and recent expert guidance calls for screening preconception and postpartum with linkage to substance use services when indicated.7 However, screening outside of prenatal care remains rare, limiting early detection and support for many patients; expanding screening and intervention efforts beyond prenatal care offers a critical opportunity for earlier intervention and support.
Several barriers hinder broader adoption. Chief among them is the persistent gap in substance use education in medical schools and OB/GYN residency curricula. Therein lies an opportunity to incorporate training into residency programmes and continuing medical education, such as implementing case-based learning focused on reproductive health-linked substance use patterns. As one example, a pilot curriculum informed by the Council on Resident Education in Obstetrics and Gynecology objectives found that targeted case-based training improved first-year OB/GYN residents’ self-reported ability to screen, counsel and refer patients with SUD to appropriate clinical and social resources.8 These programmes also increase comfort with motivational interviewing and knowledge of comorbidities, such as pregnancy complications linked to SUD.
Provider burnout is another limiting factor. Given OB/GYNs’ already demanding workload, taking on additional responsibilities can be especially challenging. Thus, expanding substance use and SBIRT training initiatives across the entire care team—nurses, midwives, medical assistants and other advanced practice providers—can help distribute the workload more sustainably and leverage the unique strengths these providers bring to behavioural healthcare. Midwives, for example, are well-positioned to engage in trusted conversations about sensitive topics like substance use, given their frequent touchpoints and long-term relationships with patients across both clinical and community-based settings. Similarly, social workers bring vital expertise in counselling and navigating local resources, rendering them uniquely equipped to address the social drivers of substance use and connect patients and families with essential clinical and community-based social services. Involving non-physician staff such as medical assistants has been shown to increase substance use screening rates significantly.9 10
Recognising the intersection between reproductive health and substance use is a critical first step towards advancing women’s health. Embedding SBIRT strategies into routine care and expanding collaborative care models are essential to this effort, helping to extend the scope of women’s healthcare practices beyond traditional boundaries. Above all, sustained progress will require aligning medical education and institutional priorities with the realities of OB/GYN practice, embedding substance use screening and related interventions as a core component of comprehensive women’s healthcare.