Virginia’s Maternal Mortality Review Team reviewed nearly 400 cases of pregnancy-associated deaths to Virginia residents occurring between 1999 and 2007. These deaths are those that happen during pregnancy or within one year of the end of pregnancy. Findings indicate substance misuse is a contributing factor in nearly one-quarter of all pregnancy-associated deaths in Virginia regardless of the actual cause or manner of death. Slightly more than 10% (41) of the deaths reviewed were the direct result of drug overdoses, mostly from accidents or suicides. In light of the magnitude and urgency of this public health problem, the Team has undertaken an in-depth review of deaths that were the direct result of drug overdoses. This multidisciplinary Team examined the circumstances leading up to the fatal event to identify where reasonable changes could be made in the systems that served women to improve outcomes in similar circumstances.