Background Women with perinatal substance problems experience barriers to care if they do not disclose their health problems. They have specific early intervention needs, they endure societal stigma, and both substances and mental health issues influence the manner how they navigate within support and treatment systems. Early interventions for women with perinatal substance problems are under-researched contexts. Methods We studied an early intervention program designed and aimed at reaching out to pregnant women and mothers with small children, which includes outreach and low threshold elements. The data consist of online written narratives from 11 workers involved in the program and feedback from 504 families in the recovery process comprised of 228 open-ended answers. The data were analyzed with a thematic analysis. Results The programs are characterized by flexibility and the implementation of new methods to approach families. The themes for enhancing relationships and engagement within outreach and low threshold programs are: Acceptance and attitude: a sensitive approach of approval; flexibility within strictness to allow for diversity and individuality; availability and space to ensure calmness in a trustful atmosphere; negotiating via doing to build connections; and everyday life changes: imagining recovery. Conclusions To enhance building connections between workers and women in need of intervention, the entire family situation needs to be acknowledged. Fathers’ or partners’ continuing substance abuse and women’s weak status in a world of substance abuse may make it difficult for women to enter and engage in treatment. One suggestion is to ensure long-term SUD treatment can be initiated during pregnancy. Many families will profit from outreach and low threshold services, so that they will not need to even enter long-standing recovery programs. By informing and messaging about substance-abuse services, for example on social media and other platforms, knowledge about such services will reach those in need. In addition, providing professionals with anti-stigma training and the general public with information about services and SUD treatment may mitigate the stigma related to substance-abuse treatment.

Background Women with perinatal substance problems experience a multitude of barriers to care. They have specific early intervention needs, they endure societal stigma, and both substances and mental health issues influence the way they navigate within support and treatment systems. Early interventions for women with perinatal substance problems are underresearched contexts. The aim of the study is to describe building relationships and engagement within an outreach and low threshold service encounter tailored for pregnant women with SUD (substance use disorder). Methods The data consist of online written narratives from 11 workers involved in the program and feedback from 504 families in the recovery process comprising 228 open-ended answers. The data were analyzed with a thematic analysis. Results The programs are characterized by flexibility and the implementation of inclusive ways to approach families. The themes for enhancing relationships and engagement within outreach and low threshold programs are Acceptance and attitude: a sensitive approach of approval; flexibility within strictness to allow for diversity and individuality; availability and space to ensure a trustful atmosphere; negotiating via doing to build connections; and everyday life changes: imagining recovery. The themes represent the need of being available, focusing on the worker’s attitudes and building connections by doing together, and visioning recovery together. Conclusions The study results can add to the understanding of SUD outreach and low threshold work during pregnancy. The elements described in this study need further theoretical development, research and critical assessment. Building relationships during pregnancy were characterized by connecting within everyday life situations and supporting the development of an attachment relationship between the baby and the parents. To promote recovery, a comprehensive approach in which substance-related issues and mental health conditions are interconnected can be favored. Engaging early on during pregnancy might enhance success during future rehabilitation.