Table 2 Emergent themes by Windle’s levels of protective factors

Pregnancy as catalyst for shift in motivation for treatment

“I needed something like an anchor, like the pregnancy because, I don’t know, I’d probably still be using to this day.” (Participant 6)

Self-management and harm reduction strategies while awaiting care

“I had known someone that was in this program and I knew that they prescribed the buprenorphine. And so that’s what I was finding on the street, because I knew that’s what they would give me.” (Participant 10)

Making the choice to disclose treatment need

“When I made my appointment I said, ‘I’m pregnant, I’m an addict, can you take me?’ It was actually a big relief.” (Participant 1)

“I was an emotional mess, but like, it was the nurse! ‘Cause you know, the list of regular questions that they have to ask. And one of the questions is, “Do you use drugs?” and I started bawling. I was like, ‘Yes, that’s why I’m here,’ and she’s like, ‘It’s all right, it’s all right, you can talk more about it when the doctor comes in.’ Like, she was super nice about it as well. I had planned on telling them on my own. But then when she asked, I was like, oh well this makes it much easier. I can just tell them the truth. Like, that’s what I’m here to do … So that I could get the help that I needed.” (Participant 10)

Development of self-efficacy and agency

“The other day, I really wanted to smoke a bowl with a couple of friends of mine. But I was like, no. For once it actually felt empowering to do something different. To do what no one else is doing. Like, the unpopular thing. It felt good to be a different person … I’m not gonna screw that up again because I’m doing so well.” (Participant 8)

Move toward self-acceptance

“I felt like the biggest piece of shit in the world for a while. I was depressed about it [using while pregnant] for a long time. And then I was like, ‘Well, it is what it is. No changing it.’” (Participant 6)

Development of self-care strategies utilizing available supports

“The transportation issue is a big thing …

The Medicaid ride brought me a lot of the time … The driver gave me his cell phone number to call, just in case, ‘cause I told him I’d had problems before [getting left at appointments].” (Participant 3)

Making decisions about relationships

“At the beginning that’s what you have to do. You have to stay away from everybody and all your friends and just not be around it. Especially if you’re not pregnant and want to get clean, because there’s nothing inside of you saying, ‘Don’t do it, because if you do you’re gonna hurt me.’ If you just want to get clean for yourself, I think you should stay away from it for like a good six, seven months.” (Participant 5)

“I was actually clean on my own for a good while … And then, I don’t know what it was … I think it was things were going on in our relationship, our marriage … It was almost like my subconscious telling me, like, ‘Oh my God. To even hang out with this motherfucker you gotta be high.’” (Participant 8)

Peer support

“When you see that these other moms are doing it … it helps to make you that much stronger, to not want to use.” (Participant 9)

Caring for others

“One of my friends comes here now … She was 4 or 5 months pregnant. She was usin’ drugs. And she just didn’t want to deal with it. But it kept gettin’ further and further … And I had given her the number plenty of times, she never called. And … she asked me if I’d give her the number again because she’s showin’ and she really needs to do something. And she was buying Suboxone [buprenorphine/naloxone] off the street. And I said, ‘You should really just go here’. And she said she’s nervous to come into a group by herself. And I told her, ‘I’ll go with you’. So she comes now every week. She’s pregnant and she comes here now.” (Participant 3)

Improved access to resources (e.g., insurance, transportation)

“I looked into it [treatment], but it was all nothing that I could afford. So I just kept doing what I was doing and getting by and I got pregnant and I got my insurance and that’s really helped out.” (Participant 1)