Opioid use disorder (OUD) in pregnancy is a complex medical condition requiring comprehensive medical, psychologic, and social care, both before and after delivery of a baby. Nationally, rates of opioid use disorder at delivery hospitalization quadrupled from 1999-2014, from 1.5 to 6.5 cases per 1,000 delivery hospitalizations.1 A parallel trend shows increasing numbers of pregnancy-associated deaths related to substance use. In Massachusetts, the proportion of pregnancy-associated mortality related to substance use has been increasing since 2011. In 2014, 1 in 5 pregnancy-associated deaths in Massachusetts were associated with substance use.2 More recent national data shows that increases in all-cause mortality are driven by drug-related mortality, and both are higher in recently pregnant people than the general female population.3 Secondary to rising rates of prenatal opioid use, rates of neonatal abstinence syndrome (NAS), which is now preferentially referred to as neonatal opioid withdrawal syndrome (NOWS), have risen greater than 5 fold since 2004. This increase has disproportionately impacted rural and publicly insured populations and has resulted in approximately $2 billion in excess Medicaid costs.4, 5, 6

These statistics speak to the need to optimize medical and psychosocial care and supports for these families. However, health care systems often find identification and adoption of best practices challenging. Structured quality improvement (QI) efforts can help systems advance their care practices and improve outcomes. In this article, we will review the evolution of QI efforts to improve care of the mother and baby impacted by opioid use disorder during pregnancy. We will highlight early efforts that targeted mother and baby separately and recent efforts that strive for coordinated care of the dyad. We will then showcase specific elements of QI frameworks exemplified in the literature, including aims, measures, and tests of change. Finally, we will review the evidence of racial inequities in the care of these families and emphasize the need for equity-focused QI efforts for this population.