Since the 1980s there has been a gradual introduction of women-centred programmes to address the needs of women who use legal and illegal drugs. But questions related to pregnancy and birth in relation to maternal drug use have proved more difficult to address and, in the USA in particular, policy and practice remains quite punitive. This article explores contemporary moral concerns and the practices related to drugs, pregnancy and mothering. It considers how sociohistoric factors have contributed to the development, or not, of women-centred harm-reduction services for pregnant women and their infants. British programmes are seen to offer public health and harm-reduction initiatives rather than just crime control. To demonstrate this, an overview of the role of a consultant midwife in providing comprehensive primary and secondary services for drug and alcohol dependent mothers in Manchester, UK is given and compared with Canadian programmes. Finally, the possible ways forward will also be explored.