Substance use in pregnancy has garnered increasing attention over the last decade as a particularly concerning facet of the larger national drug problem. This concern stems from the unique circumstance presented by pregnancy, in which the fetus may suffer harm as a result of maternal behavior. Furthermore, organizing a response to this problem is complicated by the ethically and legally challenging nature of the maternal-fetal relationship. The medical implications of perinatal substance use are profound. A discussion of these associated medical and obstetrical complications lies outside the focus of this paper, and the reader is referred to other reviews (Andres and Jones, 1994: Robins and Mills, 1993). This article is intended to assist obstetricians and others in their approach to the substance using pregnant patient. We first review the scope of this problem in social and financial terms and then review the important ethical and legal issues involved in current policymaking. Lastly, we suggest a clinical intervention focusing on education and improvement in identification and management of this subset of patients.